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SAN J OAQ U I N Environmental 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: PR#: <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling ❑Mobile Home ❑Other: _ <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. []Okay <br /> ElNeeds Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Okay <br /> ❑Needs Repair' <br /> Healer maintained in functioning and safe manner(No spacelportable heaters). El Needs <br /> Needs Re air' <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑okay <br /> ❑Needs Re air' _ <br /> All appliances(stove,water heaters,air conditioning units,heaters)are []Okay <br /> properly vented strapped and are maintained in a safe,working order. ❑Needs Repair' <br /> All smoke and carbon monoxide detectors are present and tested to be shown ❑okay <br /> In working order. ❑Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Okay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Okay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. []Okay <br /> ❑Needs Repair* <br /> All Floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑okay <br /> no water leaks and are clean and in good condition. ❑Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. []Okay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑okay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Okay <br /> ElNeeds Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. ❑Okay <br /> ❑Needs Repair* _ <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Okay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. El Okay <br /> E]Needs Repair* <br /> The gas fuel connection is as approved and safe. ❑Okay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. ❑okay <br /> ❑Needs Repair* <br /> ----------- <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Okay <br /> E]Needs Repair* <br /> "Needs Repair:Pleasespecify date repairs to be completed.Any 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 knowledge. <br /> SIGNED: <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />