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SAN 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: MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home ❑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. ❑Okay ❑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). []Okay ❑Needs Repair' Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Okayair' All rooms are clean and sanitary.No insect/rodent infestations present. ❑Okay Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are []Okay 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). []OkayElNeeds Repair* All plumbing in safe,working order(no leaks,properly maintained). ❑Okay ElNeeds Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑okay [INeeds Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑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. []OkayElNeeds 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. ❑Okay [INeeds Repair* _ Propane tank has barrier protection and'No Smoking'signage. ❑Okay [INeeds Repair* The trash cans are sufficient in size,have lids and are picked up weekly. []OkayElNeeds Repair* The electrical panel Is covered and protected from tampering. ❑Okay ElNeeds Repair* The gas fuel connection is as approved and safe. []OkayE]Needs Repair' There are no insect or rodent infestations. ❑okay ❑Needs Repair* - ----------- ----— The sewage system is functioning,with no surfacing wastewater or backup, []OkayElNeeds Repair' `Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: -- - _ - - DATE TIRE 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com