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SAN JOAQUIN Environmental Health ®apartment <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: Th 1r <br /> i <br /> LOCATION: a PR#: <br /> �� 1 A ®i <br /> HOUSING UNIT INFORMATION �4� ' MAP DESIGNATION: <br /> Address or identification number of unit: k'i C" / ' <br /> Type of Housing Unit: Z'uC0ate opion:❑SinglFamlY Dwelling [9 f� <br /> Mobile Home <br /> #Employees in Unit: f ❑Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: ,-1 <br /> HOUSING UNIT INSPECTION Gas Provided by: <br /> Interior Checklist <br /> Unit has hot end cold pinning water. Okay CommeRe <br /> nts <br /> eeds <br /> Approved electrical power and gas fuel being supplied to Unit. El NQ kay air, <br /> Heater maintained in functioning and safe manner(No space/portable heaters). El Nee s Re air* <br /> kay <br /> EI <br /> Doors and windows are accessible/operable to allow for safe exiting, Needs Okay ay air* <br /> . <br /> All rooms are clean and sanitary.No insect/rodent infestations present, Needs Okay <br /> ay air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are N ads a air* <br /> ro d vented,strapped and are maintained in a safe,workin order. Okay <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair` <br /> in workingorder, �Mkay <br /> El Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). <br /> kay <br /> All plumbing In safe,working order(no leaks,properly maintained). 0 N eds Repair* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Ne�O Ry air* <br /> ka <br /> All floors,walls,ceilin s are free from holes,are not sagging or buckling,have 01 Nee s Re air* <br /> no water leaks and are clean and In good condition. gg g g 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 loose plaster,peeling p E3 N eds Re air* <br /> P p lin Paint,holes,etc. ❑Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. El Needs Re air* <br /> Okay <br /> Propane tank has barrier protection and'No Smoking'signage, Needs ay air* <br /> Okay <br /> The trash cans are sufficient in size,have lidsand are picked up weekly. Oka <br /> Nees Ry <br /> air* <br /> The electrical panel is covered and protected from tampering, El Needs Re air* <br /> Okay <br /> The gas fuel connection is as approved and safe. Needs Re air* <br /> Okay <br /> There are no insect or rodent infestations. ❑Needs Re air' <br /> Okay <br /> Re <br /> The sewage system Is functioning,with no surfacing wastewater or backup. 11 NeedsIsair* <br /> ❑Needs Re aIP <br /> *Needs Repair.Please specifv date re airs to be completed.Any Building Permits re uired for re aibe obtained and finaled. <br /> SIGNED <br /> rs must <br /> I certify that I have inspected the above noted unit and that the information Provided is true and correct to the best d and <br /> knoed. e. <br /> DATE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 WWW.S'cehd. <br /> 1 com <br />