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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: Q f jC, PR#: LOCATION: 5� ✓ ' C�[�(i % 1� MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection—: - Type of Housing Unit: [I Single Family Dwelling obile Horne ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By.. TIrl Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water, KOkay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. kay ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters), ❑ Nee_d kay Repair* Doors and windows are accessible/operable to allow for safe exiting, kay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present. -Q�r7kay ❑Needs Re air* _ All appliances(stove,water heaters,air conditioning units,heaters)are Rtkay 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 wiring in safe,working order(no splices,exposed wires,uncovered outlets). JtVOkay ❑Need5 Repair* All plumbing in safe,working order(no leaks,properly maintained). kay ❑Needs Re air* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. tlMkay _ ❑Needs Re air* _ 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 _ 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. Okay ❑Needs Repair- Stairways are safe with no rotting,deteriorating,or loose parts, P!aOkay _ _ ❑Needs l air* 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. kay ❑ Needs Repair* The electrical panel is covered and protected from tampering. X0kay ❑ Needs Repair* _ The gas fuel connection is as approved and safe, )Okay ❑Needs Repair* There are no insect or rodent Infestations. PTOkay ❑Needs Repair* _ The sewage system is functioning,with no surfacing i stewater or backup, kay ❑Needs Repair* *Needs Re_Qwedi7lPleasespecify da re a' be completed.Any Building Permits required for repairs must be obtained and finaled. 1 certify th h e inspected th ove n t unit and that the information provided is true and correct to the best of my knowledge. SIGNED: f --7 DATE TITLE 1 V8E. Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com