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SAN J OAQ U ( N Environmental Health Department <br /> —C O U N T Y------ <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME:" h�-{/ ' -` '� PR#: <br /> LOCATION: jam{ 14d' lzil s/I ' 10MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: WSingle Family Dwelling ❑Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: 12� Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Repay air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters), kay <br /> ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑Needs Repair*_ <br /> All rooms are clean and sanitary.No InsecUrodent Infestations present. kay <br /> ❑N eds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are X0kay <br /> ._properly vented,strapped and are maintained in a safe,working order. ❑Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown kay <br /> in workinq order. ❑Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), kay <br /> ❑Needs Re air' <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition, ay <br /> [I Needs air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have kay <br /> no water leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc, 4NTokay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Needs kay air* <br /> Staim,ays are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑Needs Re air <br /> Propane tank has barrier protection and"No Smoking"signage, Okay <br /> ❑Need5 Re pal <br /> The trash cans are sufficient in size,have lids and are picked up weekly, 2rokay <br /> ❑Needs Re alr* . <br /> The electrical panel is covered and protected from tampering. PjOkay <br /> ❑Needs Repair' <br /> The gas fuel connection is as approved and safe. ?Mkay <br /> ❑Needs Repair* <br /> There are no Insect or rodent Infestations, ff0kay <br /> ❑Ned Re air* <br /> The sewage system Is functioning,with no surfacing was water or backup, El Needs ay Repair* <br /> *Needs R ir:Pleasespecify dat a airs t e completed.Any Building Permits required for repairs must be obtained and finaled. <br /> 1 certify t ave Inspected t ove no nit and that the Information provided is true and correct to the best of my knowledge. <br /> SIGNED: ✓� / Z. <br /> DATE TITLE <br /> <-868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />