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SAN 10AQUIN 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: � -� � '� <br /> LOCATION: In PR#: <br /> D;M4�• fl'� a MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:z/-/ , <br /> L (,�Date of inspection: <br /> Type of Housing Unit: W]Single Family Dwelling ❑ Mobile Home <br /> #Employees in Unit: El Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: �. <br /> HOUSING UNIT INSPECTION l Gas Provided by: <br /> Interior Checklist <br /> Unit has hot and cold running water. kay Comments <br /> Approved electrical power and gas fuel being supplied to Unit. _Np;g <br /> Ry air* <br /> ka <br /> Heater maintained in functioning and safe manner(No space/portable heaters). N s Repair* <br /> 'Okay <br /> El <br /> Doors and windows are accessible/operable to allow for safe exiting. eeds ay Repair- <br /> NZpkay <br /> kay <br /> All rooms are clean and sanitary.No insecUrodent infestations present. 0 eds air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are El eds Re air* <br /> ro erl vented,afro ed and are maintained in a safe,working order. Zbkay <br /> AIf smoke and carbon monoxide detectors are present and tested to be shown 0 Needs Repair* <br /> in workingorder, t kay <br /> All wiring in safe,working order(no splices,exposed wires, 0 eeds Repair* <br /> uncovered outlets), <br /> Okay <br /> All plumbing in safe,working order(no feaks,properly maintained). eed11 kay <br /> air* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. eeds kay ay air* <br /> All floors,walls,ceilings are free from holes,are not sa In or Ducklin ,have eeds Re air* <br /> no water leaks and are clean and in good condition. gg g g <br /> - kay <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 pl2ster,peslin O Needs Re air* <br /> g paint,holes,etc. Kay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. E eeds Re air* <br /> kay <br /> Propane tank has11 barrier protection and'No Smoking'signage. Needs air* <br /> "Bbkeyay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. 1 <ee kaR'e air* <br /> The electrical panel is covered and O Needs <br /> protected from tam tampering. (Ra air* <br /> The gas fuel connection is as approved and safe, g El Need Re air* <br /> kay <br /> There are no insect or rodent Infestations. O Needs Re air* <br /> kay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑ Re <br /> -}OCeeds kay <br /> ❑ s air* <br /> "Needs Repair:Pleases eci date repairs to be completed.AnBuildinPerm is re wired for re airs must be obtained end final <br /> I certify that I have Inspected the ab ve noted unit and that the information provided Is true and correct to the best of m knowledge. <br /> SIGNED: �i <br /> - L <br /> DATE TrrLe <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 <br /> 1 www.sjcehd.com <br />