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SAN J O A Q U I N Environmental Ileal <br /> COU N T Y--- $h Department <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: PR#: <br /> —i� <br /> HOUSING UNIT INFORMATION MAP DESIGNATION: <br /> Address or identification number of unit:�A4;1- Date of Inspection: <br /> Type of Housing Unit: ❑Single Family Dwelling obile Home <br /> #Employees in Unit: El 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 mmning water. Comments <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Repair* <br /> kay <br /> Heater 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 air* <br /> All rooms are clean and sanitary,No insect/rodent Infestations present. ❑N Okay Fe air• <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs Re air* <br /> ro rl vented strapped and are maintained in a safe workin order. Q0kay <br /> All smoke and carbon monoxide detectors are present and tested to be shown ❑Needs Repair* <br /> in workingorder, C20kay <br /> ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), kay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Need kay air' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Needs key air* <br /> 1 kay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs ay air' <br /> no water leaks and are clean and in good condition. gg g <br /> Exterior Checklist ❑Neeos Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Akay _ Comments <br /> Exterior siding is maintained with no loose taster,Peeling ❑Needs Re air* <br /> P p g paint,holes,etc. Okay <br /> Stairways are safe with no rotting,deteriorating,or loose ads .Okay. Needs aair* <br /> p .Okay <br /> Re <br /> ay <br /> tank has barrier protection and'No Smoking"signage. Needskey <br /> air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly, Need kay air' <br /> The electrical panel is covered and protected from tampering, Needs, Okay air' <br /> The gas fuel connection is as approved and safe. E] eeds Re air* <br /> Okay <br /> There are no Insect or rodent infestations. ❑Needs Re air* <br /> key <br /> The sewage system is functioning,with no surfacing wastewater or backup, ❑ e. eds Re�kay air* <br /> *Needs Re air:Please specify date re airs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I haw inspected the above noted unit and that the Information provided Is true and correct to the best of m knowled e. <br /> SIGNED <br /> y <br /> L <br /> DarE TrrrF <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 ` WW.Sjcehd.com <br />