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SAN J OAQU I N Environmental Health Department ---COUNTY—---- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST CO PLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: ` PR#: LOCATION: L-�i LL'I/I�l I '4 f/�� MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile!-tome ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: :� Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. YUbkay El Needs Repair* _ Approved electrical power and gas fuel being supplied to Unit. kay ❑Ne ds Repair* Heater maintained in functioning and safe manner(No spacelportable heaters). May -- ❑Needs Repair* Doors and windows are accessible(operable to allow for safe exiting. D�Pkay ❑N eds Repair* All rooms are clean and sanitary.No insecGrodent infestations present, kay __ ___ _0 Needs Repair* _ All appliances(stove,water heaters,air conditioning units,heaters)are Dilokay properly vented,strapped and are maintained in a safe,working order, ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown Okay in working order. _ ❑Needs Repair* All wl*ring in safe,working order(no splices,exposed wires,uncovered outlets). Ckakay _ ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay ❑Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have P<Okay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist _ Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Ukay _ ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, CKOkay _ ❑Needs Repair* Stairways are safe with no rotting,deteriorating,or loose parts. kay ❑ Needs Repair* _ Propane tank has barrier protection and"No Smoking"signage. kay -- ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Wkay ❑ Needis Repair- The electrical panel is covered and protected from tampering. -ffokay _ ❑ Needs Repair* The gas fuel connection is as approved and safe. 250kay ❑Needs Re air* _ There are no insect or rodent infestations, PKZ)kay ❑ Nee •Repair* The sewage system Is functioning,with no surfacing was .water or backup. kay ❑ Needs Repair* *Needs Re :Pleasespecify date pairs t m feted.Any Building Permits required for repairs must be obtained and finaled. I certify ave inspected the ab ve noted u it and that the Information provided is true and correct to the best of my knowledge. SIGNED: `, DATE `7 TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0 i 38 1 www.sjcehd.com