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SAN J O A Q U I N Environmental Health Department --COUNTY tF DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: Pr!G►� ;k� 'i PR#: LOCATION: MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: /5'6 3 5 A Date of Inspection: z 2—U Type of Housing Unit: ❑ Single Family Dwelling M Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: I C CJ Electrical Power Provided By: VL� 6 Gas Provided by: LAt'"1 95 HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. 11Okay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. ;POkay ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). Okay ❑Needs Repair- Doors e air`Doors and windows are accessible/operable to allow for safe exiting. 190kay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present. Okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are J90kay properly vented strapped and are maintained in a safe,working order. ❑Needs Repair' All smoke and carbon monoxide detectors are present and tested to be shown ®Okay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay ❑Needs Repair* All plumbing in safe,working order no leaks,properly maintained). •Okay P 9 9 ( P P y ) ❑Needs Re air* /zteu3CE All counters,sinks,toilets,tubs,showers are working and in sanitary condition. 00kay ❑Needs Repair' All floors,walls,ceilings are free from holes,are not sagging or buckling,have igOkay no water leaks and are clean and in good condition. ❑Needs Repair• Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. 45kay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay ❑Needs Repair* Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑Needs Repair* Propane tank has barrier protection and"No Smoking"signage. Okay El Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Ajokay ❑Needs Repair* . The electrical panel is covered and protected from tampering. Okay El Needs Re air' The gas fuel connection is as approved and safe. kay ❑Needs Repair* There are no insect or rodent infestations. 00kay ❑Needs Repair* The sewage system is functioning,with no surfacing wastewater or backup. 'Mokay ❑Needs Repair* *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: 1 DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vuww.sjcehd.com