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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: ikit3►v f 7�� S PR#: <br /> LOCATION: i5(o7)5 F-k-A cexu,,,.) C,1t MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: -Z,i to I,?- <br /> Type <br /> LType of Housing Unit: ❑ Single Family Dwelling Id Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: 0 . C Gas Provided by: 1&A-`,J75 ►Z�,�,tr`fL <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ®Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. Okay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No spacelportable heaters), okay <br /> ❑Needs Repair- <br /> Doors <br /> e air*Doors and windows are accessible/operable to allow for safe exiting. ®okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ®Okay <br /> ❑Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are [YOkay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown @Okay <br /> in working order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ®Okay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). 130kay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. QOkay <br /> ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 190kay <br /> no water leaks and are clean and in good_condition_ ❑Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> El Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. kay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. kay <br /> ❑Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup, kay <br /> ❑Needs Repair* <br /> *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> 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. <br /> SIGNED: w� Z I i&1 Z <br /> iZ- <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 />