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S A N J O A Q U I N Environmental Health Department ---COUNTY-- I DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: L'� A PR#: LOCATION: - I AP(DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Type of Housing Unit: Single Family Dwelling El Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: t,t HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. kay ❑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 Repair* Doors and windows are accessible/operable to allow for safe exiting, kay ❑Needs Re air* All rooms are clean and sanitary,No insect/rodent infestations present, kay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are J;j6kay properly vented,strapped and are maintained In a safe,workingorder. ❑Needs Repair' All smoke and carbon monoxide detectors are present and tested to be shown >Ukay in working order, ❑Needs Repair' All wiring in safe,working order(no splices,exposed wires,uncovered outlets). allkEl Needs Repey air* All plumbing in safe,working order(no leaks,properly maintained), 4Rbkay ❑Needs Re air* 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 4N,0kay 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. kay -_ ❑Needs—Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ElNeed ay Repair* Stairways are safe with no rotting,deteriorating,or loose parts. kay ❑ eeds Repair' Propane tank has barrier protection and"No Smoking"signage, 5iOkay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs 5JO Repay air' . The electrical panel is covered and protected from tampering, L@nkay ❑Needs Repair* The gas fuel connection is as approved and safe, Wkay El Needs Repair* There are no insect or rodent infestations. Wkay ❑Needp Repair* The sewage system Is functioning,with no surfacing?stew or backup, ❑Needs ay air* *Needs Repair:Pleasespecify d e rep to be completed.An Building Permits required for repairs must be obtained and finaled. I certify t ave inspected t bove r1oted unit and that the information provided Is true and correct to the best of my knowledge. SIGNED: 1 fi'5 17i ,gJ DATE r (.4/TITLE 1 8 E. Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com