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S A N J O A Q U I N Environmental Health Department --COUNTY------ DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: /`7 MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: L� Type of Housing Unit: ❑ Single Family Dwelling Nobile Home ❑ Other: #Employees in Unit: }i---Date eUUnit First Built or Installed: Electrical Power Provided By: (i Gas Provided by: L41 HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water, Wkay ❑Needs Repair* _ Approved electrical power and gas fuel being supplied to Unit. Okay ❑ Needs Repair- Heater maintained in functioning and safe manner(No space/portable heaters), kay ❑Needs Re air* Doors and windows are accessible/operable to allow for safe exiting, kay ❑ Needs Re air* All rooms are clean and sanitary.No InsecUrodent infestations present, kay _ _❑Needs Repair* _ All appliances(stave,water heaters,air conditioning units,heaters)are Okay properly vented,strapped and are maintained in a safe workinq order, _❑_Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown kay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). OROkay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). 'HOkay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay ❑Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have *kay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist 21bComments Roof is properly maintained with no holes,loose shingles,leaks,etc. kay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, ❑Needs Repair* air* Stairways are safe with no rotting,deteriorating,or loose parts, ❑Needsay Repair* Propane tank has barrier protection and"No Smoking'signage, —okay ❑ Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. ROkay ❑Needs Repair* . The electrical panel is covered and protected from tampering. okay ❑Needs Re air* The gas fuel connection is as approved and safe, Wkay ❑Needs Repair* There are no insect or rodent infestations. Xkay -- _ ❑Nee Repair* The sewage system is functioning,with no surfacing wastewater or backup, Okay ❑Needs Re air* *Needs Re a ase specify date re irs to be corrmleted.Any Building Permits required for repairs must be obtained and finaled. I certify tha nspected the abo noted u d that the information provided is true and correct to the best of my knowledge. SIGNED: _ 11 i — ?S /: �. DATE `y mu 1 8 azelton AZ I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcelid.corn