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t ' SAN J OAQ U I N Environmental Health Department <br /> ---COUNTY--- <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: ' . -, n , °e, PR#: <br /> LOCATION: ` '''`7 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:`V'7Date of Inspection: — �c' <br /> Type of Housing Unit: g Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees In Unit: i' Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> s <br /> HOUSING UNIT INSPECTION �� J <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. .©Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit, [ key <br /> ❑Needs Re air* <br /> Healer maintained in functioning and safe manner(No space/portable heaters), 00kay <br /> ❑Needs Repal <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑Needs Re all <br /> All rooms are clean and sanitary.No Insect/rodent infestations present, Okay <br /> All appliances(stove,water heaters,air conditioning units,heaters)are eeds ay air' <br /> ro erl vented stra ed and are maintained in a safe,workin order. ❑NeLe�dskRepair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in workin order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered cutlets), Okay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). 000 ay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition.J[01 J�Okey <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Need ka a air• <br /> no water leaks and are clean and in good condition. v <br /> ❑Weeds Repair' <br /> Exterior Checklist <br /> Comments <br /> Roof is properly maintalned with no holes,loose shingles,leaks,etc. Okay -- <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. O kay <br /> ❑Needs Re air' <br /> Propane tank has barrier protection and'No Smoking"signage. L3 kay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly, Okay <br /> ❑Needs Re air*. <br /> The electrical panel is covered and protected from tampering. OOkay <br /> ❑Needs Re air* <br /> The gas fuel connection is as approved and safe. OOkay — <br /> ❑Needs Repair* <br /> There are no insect or rodent Infestations. L-Jkay <br /> Needs Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. C3Dkay <br /> fEE]Needs Re air" <br /> "Needs Repair:Pleasespecifydate repairs to be com leted.An Building Permits required for repairs must be obtained and finaled. <br /> 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. <br /> SIGNED: / <br /> �1 ��� r �.• "� r. — <br /> T !G — <br /> L <br /> DATE Time <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />