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SAN 10A Q U I N Environmental Health Department COUNTY----- p 1�:, 6re:ntrn:ss qrr•;, .. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: E- , . ?%j u� PR#: LOCATION: 0 1 juA_)0kA_ i" ' : r! MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: 1 -- <` '` ate of Inspection: Type of Housing Unit: Z Single Family Dwelling ❑ Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: 1l� Electrical Power Provided By; Gas Provided by: HOUSING UNIT INSPECTION )l Interior Checklist Unit has hot and cold running water. Okay Comments ❑Needs Re air* Approved electrical power and gas fuel being supplied to Unit. []Okay ❑Needs Re air* Heater maintained in functioning and safe manner(No space/portable heaters), QMay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting, okay ❑Needs Re air" All rooms are clean and sanitary.No insect/rodent infestations present. ©Okay All appliances(stove,water heaters,air conditioning units,heaters are Needs Repair* ro erl vented,strapped and are maintained In a safe,workingorder. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown ©okay in workinq order, ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). C�kay ❑Needs Re air` All plumbing in safe,working order(no leaks,properly maintained). 12Okay ❑Needs Re air* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. []Okay All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs Re air* ay no water leaks and are clean and in good condition. Beds R Needs R Exterior Checklist Needs Roof is properly maintained with no holes,loose shingles,leaks,etc. Comments kay ❑Needs Re air' Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, "ay ❑ eeds Re air* Stairways are safe with no rotting,deteriorating,or loose parts. QOkay ❑Needs Repair* Propane tank has banner protection and'No Smoking"signage. L30kay ❑Needs Re air* The trash cans are sufficient in size,have lids and are picked up weekly. 130kay ❑Needs Repair . The electrical panel is covered and protected from tampering. E3 kay _LLNeeds Re air* The gas fuel connection is as approved and safe. [20kay El Needs Repair* There are no Insect or rodent infestations. ]okay ❑Needs Re air* The sewage system Is functioning,with no surfacing wastewater or backup. []Okay ❑Needs Re air* *Needs Re air:Pleasespecify date repairs to be Com leted.Any Building Permits required for repairs must be obtained and finaled. I certify that I have 11lns12 ected the above noted unit and that the Information provided Is true and correct to the best of my knowledge. SIGNED: Z_><L DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjoehd.com