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SAN 10AQUIN Environme <br /> —COUNTY// ntal Health Department <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: PR#; <br /> HOUSINGUNIT INFORMATION MAP DESIGNATION: <br /> Address or identification number of unit,: v�-t ) Date of Inspection: JGf <br /> c c 7 <br /> Type of Housing Unit: p Single Family Dwelling ❑Mobile Home <br /> #Employees in Unit: 1-1 Other- <br /> Date Unit First Built or In <br /> Electrical Power Provided By; '�_ �� <br /> HOUSING UNIT INSPECTION Gas Provided by: <br /> Interior Checklist <br /> Unit has hot and cold running water. Okay Comments <br /> Approved electrical power and gas fuel being supplied to Unit, <br /> Heater maintained in functioning and safe manner(No space/portable heaters), ❑Needs eed kReey air "air• <br /> ❑ `90kay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑NeedLdOkay air" <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑ 00kay air" <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs Re air" <br /> ro erl vented,straed and are maintained in a safe,workin order. 00kay <br /> All smoke and carbon monoxide detectors are present and tested to e shown ❑Needs Repair* <br /> in working b <br /> order. key <br /> ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Ne Okay air* <br /> All counters,s(nks,toilets,tubs,showers are working and in sanitary condition. El Needs ay air" <br /> Okay <br /> All floors,walls,ce lings are free from holes,are not sagging or buckling, ❑ eeds Re air* <br /> no water leaks and are clean and In good condition. g [Okay <br /> Exterior Checklist ❑Needs Repair" <br /> Roof Is properly maintained with no holes,loose shingles,leaks,etc. kay Comments <br /> Exterior siding is maintained with no loose faster, ea' ❑Needs Repair* <br /> P peeling paint,holes,etc. Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Re air' <br /> . Okay <br /> Re <br /> Propane tank has barrier protection and'No Smoking"signage. El eeds Okaayy air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. dOkay The <br /> The electrical panel is covered and protected from tampering• fdeBOkay air' <br /> Re <br /> The gas fuel connection is as approved and safe. El Needs Okaayy air <br /> There are no insect or rodent Infestations. ❑ eeds Re air' <br /> Okay <br /> Re <br /> The sewage system Is functioning,with no surfacing wastewater or backup, eeds <br /> eOkey air" <br /> eeds Re air* <br /> 'Needs Repair:Please s ecify date re airs to be cam feted.Any Building Permits require for re airs must be obtained and final <br /> 1 cern that have inspected the above noted unit and that the information roand correct to the best of my <br /> SIGNEed is true <br /> knowled e.D: 'J� '' vid�/ 7y <br /> DATE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-01381 www.sjcehdehd.com <br />