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SAN JOAQUIN Environme <br /> --COUNTY ntai 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: <br /> LOCATION; A PR#: <br /> ]�;3�1 y MAP DESIGNATION: <br /> HOUSING UNIATION <br /> Address or identification number of unit: 2 L. q;�) <br /> `il(JjO ate of Inspection: h­ <br /> Type of Housing Unit: ❑Single Family Dwelling 0 Mobile Home <br /> #Employees in Unit: El Other; <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By; (.., .. Gas Provided by: L'��L ) <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist <br /> Unit has hot and cold running water. OkCommenfs <br /> ay <br /> eds <br /> Approved electrical power and gas fuel being supplied to Unit. NEI' ekay air' <br /> eeds Re <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑WJDOkay air' <br /> Doors and windows are accessible/operable to allow for safe exiting. 0 Needs Re air' <br /> Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present, Needs Re air; <br /> 30kay <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs Repair* <br /> ro erl vented,stra ed and are maintained In a safe,workin order. (9bkay <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair* <br /> in workingorder, pbkay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), Needs Repair* <br /> kW <br /> All plumbing in safe,working order(no leaks,properly maintained). Need kay air* <br /> All counters,sinks,toilets,tubs,showNeed Re air* <br /> ers are working and in sanitary condition. <br /> Okay <br /> All floors,walls,ceilings are free from holes,are not sagging=b,,cllin,, Needs Re air• <br /> no water leaks and are clean and In ood condition, I3akay <br /> Exterior Checklist ❑Needs Repair" <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. k3 key Comments <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Needs Re air"okay <br /> Stairways are safe with no rotting,deteriorat0 Needs Re air* <br /> ing,or loose parts, <br /> kay <br /> Propane tank has barrier protection and'No Smoking'signage. Needs kay air' <br /> Re <br /> The trash cans are sufficient In size,have lids and are picked up weekly. NBBOkay all <br /> The electrical panel is covered and protected from tampering. Need Re air* . <br /> ,aOkay <br /> The gas fuel connection is as a Needs,Re airy <br /> pproved and safe, OOkay <br /> There are no Insect or rodent infestations. O Needs-Re kay air' <br /> ay <br /> The sewage system is functioning,with no surfacing wastewater or backup, Needs kay air' <br /> "Needs Repair.Please s eci date repairs to be corn leted.Any Building.Needs <br /> BuildiPermits reuired for re airs must be obtained and finaled <br /> I certify that I have Inspected the above noted unit and that the Information provided is true and c rrect to the best of m knowied e. <br /> SIGNED; /��' <br /> t Gc. 1 C <br /> DATE <br /> TfTI.E <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 WWW.sjcehd.com <br />