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SAN JOAQUIN [Environmen <br /> COUNTY tai Health ®apartment <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> FACILITY NAME: <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> �= <br /> LOCATION: i? <br /> HOUSING UNIT INFORMATION �� MAP DESIGNATION: <br /> Address or identification number of unit: )- <br /> G -4r i)/L Oate of Inspection: o C 3,,/ <br /> Type of Housing Unit: M Single Family Dwelling ❑ Mobile Home <br /> #Employees in Unit: ❑Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: <br /> V 6 Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist <br /> Unit has hot and cold running water. kay Comments <br /> Approved electrical power and gas fuel being supplied to Unit. El Need4jukay Repair- <br /> power <br /> maintained In functioning and safe manner(No space/portable heaters). Needs' kay air* <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Re air* <br /> kay <br /> All rooms are clean and sanitary.No Insect/rodent infestations present, El Needs Re air* <br /> kay <br /> All appliances(stove,water heaters,air conditioning un(ts,heaters)are Needs Re air* <br /> properly vented,stra ed and are maintained in a safe workin order. POkay <br /> All smoke and carbon monoxide detectors are present and tested to be shown ❑Needs Repair" <br /> in working order. Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑NAeds Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,property maintained). ❑Niteds <br /> Okay air* <br /> All counters,sinks,toilets,tubs,showers are working key <br /> and in sanitary condition. ❑N eds Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs y air• <br /> no water leaks and are clean and In good condition, ka <br /> Exterior Checklist ❑ eds Repair* <br /> Roof Is properly maintained with no holes,loose shingles,leaks,etc, okay Comments <br /> Exterior siding is maintained with no loose plaster,peeling ❑N eds Re air* <br /> paint,holes,etc. Okay <br /> StaiRe <br /> rways are safe with no rotting,deteriorating,or loose parts, ❑Needs key air* <br /> Propane tank has barrier protection and"No Smoking"signage. N Reds Re air* <br /> Okay <br /> The trash cans are sufficient In size,have lids and are picked up weekly. ❑- IOkay air* <br /> The electrical panel Is covered and protected from tampering. "reeds ky aair*. <br /> The gas fuel connection is as approved and safe. ❑ ads Re air* <br /> Okay <br /> There are no insect or rodent Infestations. ❑Needs Re air* <br /> Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑N e kay air* <br /> "Needs Re ir..Pleases eci date repairs to be com leted.An❑guildins Perm's re wired for repairs must be obtained end finaled. <br /> I certl that I have Inspected the above noted unit and that the Information provided is t ue and correct to the best of m knowled e. <br /> SIGNED: 7 <br /> Tm.E <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />