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SAN J O A Q U I N Environmental Health Department —C O U N T Y----- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: ,f"` 'A � '6 ie-- PR#: LOCATION: ' 6 04:47 MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Lc} "Cl Date of Inspection: Type of Housing Unit: [j'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. ay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. key ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). ©okay ❑Needs Re aif Doors and windows are accessible/operable to allow for safe exiting, 20kay ❑Needs Re air* All rooms are clean and sanitary.No insect/rodent infestations present. Okay All appliances(stove,water heaters,air conditioning units,heaters edk are Needs ay air* properly vented,stra ed and are maintained in a safe workingorder. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown pbkay In working order, ❑Needs Repair` All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E30kay ❑Needs Repair* All plumbing In safe,working order(no leaks,properly maintained). [20kay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. [:30kay El All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs[Okaay y air• no water leaks and are clean and in good condition. ❑Needs Repair` Exterior Checklist Roof Is properly maintained with no holes,loose shingles,leaks,etc. Okay Comments ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. 20kay ❑Needs Repair' Stairways are safe with no rotting,deteriorating,or loose parts. 120kay ❑Needs Re air* Propane tank has barrier protection and"No Smoking"signage. Dkay ❑Needs Re air* 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. WOk2y ❑Needs Repair* The gas fuel connection is as approved and safe. ,[Okay ❑Needs Re air` There are no Insect or rodent Infestations. C20kay ❑Needs Re air* The sewage system Is functioning,with no surfacing wastewater or backup, E20kay ❑Needs Re air` *Needs Rep air.Pleasespecify date re airs to be com feted.Any Building Permits required for repairs must be obtained and finaled. 1 certify that I haveInspected the above noted unit and that the Information provided Is true and correct to the best of my knowledge. SIGNED: DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com