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SAN J 0 A Q U I N Environmental Health Department —COU NTY-- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: ikl0► ;NV—M S PR#: LOCATION: 151o,55 � XJ C,1% 9S ZL, MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: !5 3 5 1-lov5 E Date of Inspection: 2 Z(r Type of Housing Unit: ® Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: ' Date Unit First Built or Installed: I C1 S 0 Electrical Power Provided By: C, C Gas Provided by: t&#-,v1A S iz, ,-A.J C— HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. ®Okay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. ®Okay ❑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. ®Okay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present. kay Ej.Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ®Okay 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 90kay in working order. ❑Needs Repair' All wiring in safe,working order(no splices,exposed wires,uncovered outlets). WOkay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ®okay ❑Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have ®Okay no water leaks and are clean and in good condition. _ _ ❑Needs Repair' Exterior Checklist 4ffComments Roof is properly maintained with no holes,loose shingles,leaks,etc. okay ❑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 ❑Needs Repair* _ The trash cans are sufficient in size,have lids and are picked up weekly. ElNe&ed kRe air' C-4-C-AU VIZA S The electrical panel is covered and protected from tampering. J90kay ❑Needs Repair* The gas fuel connection is as approved and safe. kay ❑Needs Repair* There are no insect or rodent infestations. Okay ❑Needs Repair* The sewage system is functioning,with no surfacing wastewater or backup. ❑Needsay 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 th ve noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: �. j C LL: C'wrJ L fL DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com