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SAN JOAQUIN Env,r®n <br /> --COUNTY-- mental Health ®apartment <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING 1NSPECTION CHECKLIST <br /> FACILITY NAME: <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> - ' <br /> I. <br /> LOCATION: PR#: <br /> -)Aa = MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION ' <br /> Address or identification number of unit: ' �- <br /> =���t1� LC.r. -/f7d Date of Inspection: -- <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 /> rUnnit <br /> ING UNIT INSPECTION l F Gas Provided by: <br /> or Checklist <br /> as hnt and coldrunning water. Comments <br /> Okayved electrical power and gas fuel being supplied to Unit. ❑N%00kay air• <br /> Heater maintained in functioning and safe manner(No space/portable heaters), <]Needs Okay ay air* <br /> ❑Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. l ds R <br /> All rooms are clean and sanitary.No insecUrodent infestations present, El Needs R air* <br /> Alll appliances(stove,water heaters,air conditioning units,heaters)are Ne ds Repair* <br /> ro erl vented,straped 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. F;3bkay <br /> ED <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), _Needs <br /> Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). eeds Re air• <br /> Okay <br /> All counters,sinkstoilets,tubs,showers are working and in sanitary condition. Needs ay air* <br /> , f�l0k <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling, Needs Re air* <br /> no water leaks and are clean and in good condition. g okay <br /> Exterior Checklist ❑N eds Repair" <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc, Okay Comments <br /> Exterior siding is maintained with no loose plaster,peelin g paint,holes,etc. Needs Oky aair* <br /> Stairways are safe with norotting,deteriorating,or loose parts, Needs Re air* <br /> Okay <br /> Propane tank has barrier protection and"No Smoking'signage. Needkay air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Needkay air' <br /> The electrical panel is covered and protected from tampering, Needs Cf70ky aair* . <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 /> The sewage system is functioning,with no surfadng wastewater or backup, Needs R air* <br /> "Needs I h air:Pleases eci date repairs to be com feted.An❑Buildindii;s Perm is required for ust be obtained and finale <br /> re airs m <br /> SIGNED <br /> I certify that had. <br /> ve inspected the above noted unit and that the Information provided is true and correct to the best of my knowledge. <br /> : - �� <br /> L �l / ._ 3 <br /> DATE <br /> TrT�e <br /> 1868 E. Hazelton Avenue( Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />