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SAN JOAQUIN Environ <br /> COUNTY menti 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: btAv - y k <br /> LOCATION: fill PR#; <br /> OUSING <br /> HUNIT INFORMATION I / �� MAP DESIGNATION: <br /> Address or identification number of unit; <br /> Date of Inspection: -61-- <br /> Type of Housing Unit: L&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 /> Inferior Checklist <br /> Unit has hot and cold Winning wafer. Comments <br /> Ok11 ay <br /> Approved electrical power and gas fuel being supplied to Unit. Ne Dkay air' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Ne11 eds aair* <br /> Okayy <br /> Re <br /> Doors and windows are accessible/operable to allow for safe exiting. Needs <br /> 00kay air* <br /> El Re <br /> All rooms are clean and sanitary.No insect/rodent infestations present, Needs key air* <br /> All appliances(stove,water heaters,air conditioning units,heaters are [I Needs Re air* <br /> ro rl vented stra ed and are maintained in a safe,working order. Needs <br /> R <br /> All smoke and carbon monoxide detectors are present and tested to be shown l]Needs Repair* <br /> in workingorder. kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), E N eds Repair* <br /> kay <br /> All plumbing In safe,working order(no leaks,properly maintained). 0 Nees Repair* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. El N e. s Repair*___ <br /> Okay <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, gg g ❑Okay <br /> Exterior Checklist <br /> ❑N�feds Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. gOkay — Comments <br /> , <br /> Exterior siding is maintained with no loose tastereelln [I Needs Re air* <br /> P P g paint,holes,etc. Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ed Re key air* <br /> s Re <br /> Propane tank has barrier protection and'No Smoking'signage, ❑ e.Okay <br /> air* <br /> The trash cans are sufficient In size,have lids and are picked up weekly, eOkay ds Re air* <br /> The electrical panel is covered and protected from tampering, eeds Re air* <br /> kay <br /> The gas fuel connection is as approved and safe. El N eds Re air* <br /> iRO�y <br /> El N <br /> There are no insect or rodent infestations. eds Re air* <br /> Okay <br /> Re <br /> The sewage system Is functioning,with no surfacing wastewater or backup. NeeP)key air* <br /> L1 Needs Repair* <br /> `Needs Repair Pleases ec' date re airs to be completed.Any Buildin Permits rawired for repairs must be obtained and finaled. <br /> I certify that i have Inspected the above noted unit and that the Infor <br /> SIGNED <br /> mation provided is true a correct to the best of m knowied e. <br /> i <br /> TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 www.sjcehd.com <br />