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SAN JOAQUIN Environmental Health Department COUNTY DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: /\ MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit:/ L% C)l ate of Inspection: Type of Housing Unit: 0 Single Family Dwelling ❑Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. V05kay ❑Needs Re air* Approved electrical power and gas fuel being supplied to Unit. okay ❑Needs Repair* Heater maintained in functioning and safe manner(No spacelportable heaters). Okay ❑N�eedudsRe air* Doors and windows are accessible/operable to allow for safe exiting. kayElds Re air* All rooms are clean and sanitary.No insect/rodent Infestations present, kay ❑N eds Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ��bka properly vented strapped and are maintained in a safe,workingorder. El Meds Repair* All smoke and carbon monoxide detectors are present and tested to be shown UDkay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets), key ❑N eds Re air* All plumbing In safe,working order(no leaks,properly maintained), UOkay ❑N eds Re air* All counters,sinks,toilets,tubs,showers are working and in sanitary condition, kay ElN'eds Re air* All floors,walls,ceilings are free from holes,are not sagging or buckling,have WfOkay no water leaks and are clean and in good condition. ❑Nbeds Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. okay ❑Needs Re air" Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay ee ❑ s Re air" Stairways are safe with no rotting,deteriorating,or loose parts. Okay El Needs Re air* Propane tank has barrier protection and'No Smoking'signage. kay ❑ eds Re alr* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑NT3eds Repair* The electrical panel is covered and protected from tampering. Okay ❑N eeds Re air* The gas fuel connection is as approved and safe. kay -- ❑ Re air* There are no insect or rodent Infestations, kay N eds Re air* The sewage system is functioning,with no surfacing wastewater or backup. kay ❑Needs Repair* *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. 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. SIGNED: / r v DATE Tnr� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vwvw.sjcehd.com