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SAN JOAQUIN Environmental Health Department <br /> —C O U N T Y------ <br /> ' <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: f >'�' ' PR#: <br /> LOCATION:, 1 k13 " ' r MAp DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 1 �' <br /> _'rGlj�) Date of Inspection: <br /> Type of Housing Unit: Osingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: �J-! Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑Needs a air* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑Needs Re air' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). J20kay <br /> ❑Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. ji- Okay <br /> ElNeeds Re air* <br /> All rooms are clean and sanitary.No Insect/rodent infestations present. 120kay <br /> All appliances(stove,water heaters,air conditioning units,heaters eek <br /> are ❑Needs ay air* <br /> properly vented strapped and are maintained in a safe,workingorder, ❑Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown pOkay -in working order. ❑Needs Repair' <br /> All wiring In safe,working order(no splices,exposed wires,uncovered outlets), Beds <br /> ❑Needs Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained). 20kay <br /> ❑Needs Repel <br /> All counters,sinks,tollets,tubs,showers are working and In sanitary condition. ,©Okay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs Re air" <br /> no water leaks and are clean and in pood condition. .00kay <br /> Exterior Checklist ❑Needs Repair' <br /> Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. D"Okay <br /> ❑Needs Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, Ja0kay <br /> Needs Repair <br /> Stairways are safe with no rotting,deteriorating,or loose parts, Okay <br /> ❑Needs Re air* <br /> Propane tank has barrier protection and'No Smoking"signage, key <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. [QOkay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. 00kay <br /> Needs Repair* <br /> The gas fuel connection is as approved and safe. JrTOkay <br /> Needs Repair* <br /> There are no insect or rodent Infestations. [aOkay <br /> ❑Needs Re air* <br /> The sewage system is functloning,with no surfacing wastewater or backup, ©Okay <br /> Needs Re air` <br /> 'Needs Re air:Pleases eci date re airs to be Com leted.Any Buildin Permits required for repairs must be obtained and finaled. <br /> 1 certify that I have Inspected the above noted unit and that the Information provided Is true and correct to the best of my knowledge. <br /> SIGNED: :] i <br /> DATE ` Tine j <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />