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SAN JOAQUIN Environmen <br /> COUNTY— til 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: inil <br /> PR#: <br /> HOUSING UNIT INFORMATION T�- MAP DESIGNATION.- <br /> Address <br /> ESIGNATION:Address or identification number of unit;" �ns <br /> Type -� !y�� = �•(iL_',v��Date of Inspection: le� .� � _ � .• <br /> yp 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 /> Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist <br /> Unit has hot and cold running water. Comments <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑NeedsOkay <br /> Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Needs Re air* <br /> Okay <br /> Needs Re air` <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> All rooms are clean and sanitary.No insect/rodent infestaticns present, 11 Needs Re air* <br /> Okay <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs Re air* <br /> properly vented,stra d and are maintained in a safe,workin order. eelsE�by <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair* <br /> in workingorder. Okay <br /> All wiring in safe,working order(no splices,exposed wires, EI N ads Repair" <br /> uncovered outlets). <br /> Okay <br /> All plumbing in safe,working order(no leaks,property maintained). Needs ey air* <br /> All counters,sinksEl, kay toilets,tubs,showers are working and in sanitary condition. f�]ads air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs Re air* <br /> no water leaks and are clean and in good condition QCkay <br /> Exterior Checklist ❑N eds Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. �90koy Comments <br /> Exterior siding Ismaintained with no loose plaster,peelingNeeds Re air` <br /> paint,holes,etc. Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. El Needs Re air* <br /> .I Okay <br /> Propane tank has barrier protection and'No Smoking'signage. 1:1 Needs Re air* <br /> key <br /> eeds Re <br /> The trash cans are sufflcient In size,have lids and are picked up weekly. NPOkay air* <br /> The electrical panel is covered and protected from tampering, Needs Re air* <br /> Okay <br /> The gas fuel connection Isas approved and safe. El Needs Re air* <br /> ;?Okay <br /> There are no insect or rodent Infestations, ❑Needs Re air* <br /> kay <br /> The sewage system is functioning,with no surfacing wastewater or backup, Needs l�bkay air* <br /> El Needs Re air* <br /> *Needs Re air:Please s eci date repairs to be completed.Anv Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have Inspected the above noted unit and that the Information provided is true and correct to the best of my knouried e. <br /> SIGNED <br /> DATE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138TRS <br /> I `^^"w.sjcehd.com <br />