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SAN JOAQUIN kEnv;r®n <br /> rnental 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: y =* <br /> ' <br /> LOCATION: / � ,� fi � � PRM <br /> A, <br /> HOUSING UNIT INFORMATION MAP DESIGNATION: <br /> Address or identification number of unit;_ ] / <br /> -, t • Date of Inspection: f <br /> Type of Housing Unit: m Single Family Dwelling LJ Mobile Home <br /> #Employees in Unit: El Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: <br /> Gas Provided by: <br /> HOUSING UNIT INSPECTION y 6 f ljIII <br /> Interior Checklist <br /> Unit has hot and cold running water. OkComments <br /> ay <br /> ❑Needs III <br /> Approved electrical power and gas fuel being supplied to Unit. Lwokay <br /> Re <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). El Ne(I kay air* <br /> eeds Re <br /> Doors and windows are accessible/operable to allow for safe exiting. ID N[POkay air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑NQOkay eeds Re air' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs ay air* <br /> Properly vented,stra ed and are maintained in a safe,workingorder. Okay <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair* <br /> in workingorder. QOkay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Needs Repair" <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑N eds Re kay air* <br /> All counters,sinks,toilets,tubs,showers are working and in sancta condition. :1111 Re air* <br /> sanitary WOkay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have El Needs Re air* <br /> no water leaks and are clean and In ood condition. ©Okay <br /> Exterior Checklist El Needs Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ['okay Comments <br /> Exterior siding is maintained with no loose piaster,peeling El Needs Re air* <br /> g paint,holes,etc. (f7okay <br /> Re <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Ne-1Okay air* <br /> Propane tank has barder protection and"No Smoking"signage. Needs`Okay ay air* <br /> The trash cans are sufficient In size,have lids and are picked up weekly. �lOkaNeeds Ry air* <br /> eeds Re <br /> The electrical panel is covered and protected from tampering. El NQOkay air'. <br /> The gas fuel connection Is as approved and safe. 11 Needs Re air* <br /> Okay <br /> There are no Insect or rodent infestations. O Needs ll <br /> I <br /> Os <br /> The sewage system is functioning,with no surfacing wastewater or backup. N00kayRepair* <br /> Re all <br /> "Needs Re air.Pleases eci date re airs to be com leted.Any Buf d needs <br /> yPerm is- utred forairs must be obtained and finaled. <br /> I certify that I have inspected the above noted unit and that the <br /> SIGNED: Information provided is true and correct to the best of my knowled e. <br /> y <br /> DATE <br /> TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468m34201 F 209 464-0138 1 WWW.Sjcehd.com <br />