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SAN JOAQUIN Environn7 <br /> -- <br /> 'COUNTY--- <br /> ental Health ®apartment <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: Ia .--, <br /> fN� -------------- <br /> LOCATION: PR#: <br /> HOUSING UNIT INFORMATION y MAP DESIGNATION: <br /> Address or identification number of unit:- ; <br /> - `�% �5, Z/Ai1PfLJ Date of inspection- 16) <br /> Type of Housing Unit: ❑Single Family Dwelling [�]Mobile Home <br /> #Employees in Unit: ❑Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: <br /> HOUSING UNIT INSPECTION v 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. El Needs Re air* <br /> a <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Weeds kaay air* <br /> Doors and windows are accessible/operable to allow for safe exitingEl N ads Re air* <br /> . Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present, ❑NWOkay air* <br /> Ali appliances(stove,water heaters,air conditioning units,heaters)are -10 1;3Needs Re air* <br /> ro erl vented,strapped and are maintained In a safe,work <br /> order, Okay <br /> All smoke and carhop monoxide detectors are present and tested to be shown Needs Repair* <br /> in workin order. I�.okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Ndeds Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). Needs Re air* <br /> 0Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. El Needs Re air* <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. Okay <br /> Exterior Checklist ❑Needs Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc, Okay Comments <br /> Exterior siding is maintained with no looseee6n laster, El Needs Re air* <br /> P peeling paint,holes,etc. okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. N8VOkay air* <br /> Propane tank has barrier protection and"No Smoking"signage. Cl Needs Re air* <br /> ;1Okay <br /> The trash cans are sufficlent In size,have lids and are picked up weekly, El Needs R air* <br /> PokeThe electrical panel Is covered and protected from tampering. Q N eds Re air*. <br /> Okay <br /> The gas fuel connection is as approved and safe. Needs Okaayy air' <br /> There are no insect or rodent infestations. ❑Needs Re air* <br /> kay <br /> The sewage system is functioning,with no surtaang wastewater or backup, [I Needs Re air* <br /> [,okay <br /> "Needs Re air.Pleases specify date re airs to be com leted.An❑Buildins Permt s re uired for reairs must be obtained and finaled <br /> I certi that i have inspected the above noted unit and that the information provided is true and correct to the best of my knowled e. <br /> SIGNED <br /> C� Ai /D <br /> Tlrl.e <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.Sjcehd.com <br />