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SAN J O A Q U I N 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: R E"- _ -N6 Ue. PR#: <br /> LOCATION: ! I '}' eOl r ('x MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number ofunit;_ �� �l�j� ate of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Erfbkay <br /> ❑Needs Re air* <br /> Approved electrical power and gas fuel being supplied to Unit, 'kay <br /> Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). 1�40kay <br /> ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting, Okay <br /> ❑Needs Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present, 4QQkay <br /> Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 1, ka <br /> properly vented strapped and are maintained in a safe,workingorder. ❑N€eeds Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown zQOkay <br /> in working order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). �7'Okay <br /> ❑Needs Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> eeds Re air' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ��kay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑ Oke a air' <br /> no water leaks and ❑Needs R <br /> are clean and in good condition. y <br /> epair• <br /> Exterior Checklist <br /> Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. WOkay <br /> _0 Weeds Repair* <br /> Exterior siding Is maintained with no loose plaster,peeling paint,holes,etc, Okay <br /> eeds Re air" <br /> Stairways are safe with no rotting,deteriorating,or loose parts. 4,,JOkay <br /> ❑Needs Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. kay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have Gds and are picked up weekly. ZOkay <br /> ❑Needs Re air*. <br /> The electrical panel is covered and protected from tampering, kay <br /> Needs Repair* <br /> The gas fuel connection is as approved and safe. k�Okay — <br /> eeds Re air* <br /> There are no insect or rodent Infestations. Okay <br /> ❑Needs Re al <br /> The sewage system Is functioning,with no surfacing wastewater or backup. =ONeeds <br /> Okay <br /> Re alr" <br /> *Needs Repair.Pleasespecify date repairs to be completed.Any BuIldina Permits required for repairs must be obtained and flnaled. <br /> 1 certify that 1 have Inspected the above noted u it and that the information provided Is rue nd correct to the best of m knowledge. <br /> SIGNED: \ ] Z <br /> C7 <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />