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SAN JOAQUIN Environm <br /> ----COUNTY ental Health ®apartment <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: r <br /> LOCATION: /'" <br /> i ' PR#: <br /> HOUSING UNIT INFORMATION + MAP DESIGNATION: <br /> Address or identification number of unit: () Date of�Inspection: 6 i 7 <br /> ' <br /> Type of Housing Unit: )Single Family Dwelling ❑Mobile Home <br /> #Employees in Unit: ❑Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: <br /> HOUSING UNIT INSPECTION € Gas Provided by: <br /> Interior Checklist <br /> Unit has hot and cold running water. kComments <br /> ay <br /> ❑Needs Re air" <br /> Approved electrical power and gas fuel being supplied to Unit. L]Okay <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). Needs/ ka air* <br /> ay <br /> Doors and windows are accessible/operable to allow for safe exiting. Ej Needs ay air* <br /> El <br /> All rooms are clean and sanitary.No insect/rodent infestations present.All skay air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are [j Needs Re air* <br /> ro erl vented,stra ed and are maintained in a safe workin order. eelsi�bRepair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs <br /> in workin order, ®okay <br /> El Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). <br /> kay <br /> All plumbing in safe,working order(no leaks,properly maintained), ❑Needs Re <br /> air* <br /> POkaAll counters,sinks,toilets,tubs,showRe <br /> ers are working and in sanitary condition. El Needsand <br /> air* <br /> All floors,walls,ceilings are free from holes,are not sagging or bucklin El Needs ay air' <br /> ,have <br /> no water leaks and are clean and in ­1 condition, g ;40k <br /> Exterior Checklist ❑Needs Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay Comments <br /> Exterior siding is maintained with no loose Plaster, Needs a air* <br /> P peeling paint,holes,etc. OkaEly <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Needs Okay aair* <br /> Okay <br /> Propane tank has barrier protection and"No Smoking'signage. El N eds Re air* <br /> Okay <br /> The(rash cansare sufficient In size,have lids and are picked up weekly. Ne"'Okay air* <br /> The electrical panel is covered and protected from tam erin . Ej N eds Re air*. <br /> p g Okay <br /> The gas fuel connection is as approved and safe, N eds Re air*kay <br /> O <br /> There are no Insect or rodent Infestations. N eds Okay <br /> air* <br /> The sewage system is functioning,with no surfaaNeeds Re air* <br /> ng wastewater or backup. <br /> Okay <br /> `Needs REl Needs Re air* <br /> e alr:Pleases ea date re airs to be completed.Ant Building Permits reuired far re airs must be obtained and finale <br /> I certify that I have ins acted the above noted unit and that the Infortnatlon rovlded Is true an correct to the best of m knowled e. <br /> d. <br /> SIGNED: 7 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138TITLE <br /> I www.sjcehd.com <br />