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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: A TID1� ;klt-m�1 PR#: <br /> LOCATION: 1 rJ Io3 Cj .J CA q53LL' MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 16yjl,Z Date of Inspection: j i1 2 L--- <br /> Type <br /> dType of Housing Unit: 90 Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: S(:t <br /> Electrical Power Provided By: TC„ Gas Provided by: AJ A <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ®Okay <br /> ( <br /> Needs Repair* <br /> R <br /> El <br /> Approved electrical power and gas fuel being supplied to Unit. ®Okay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ®Okay <br /> ❑Needs Repair* <br /> 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 ®Okay <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). ®okay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. tgOkay <br /> ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have pOkay <br /> no water leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior Checklist Comments r <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. El NAOkRds e air ` ATG �7 IZ rf 7c f <�Arp4`1 <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. {5Ok2y <br /> ❑Needs Repair' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ®Okay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. iffOkay <br /> ❑Needs Repair <br /> The trash cans are sufficient in size,have lids and are picked up weekly. 00kay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. 00kay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. Jj�Okay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. ®okay <br /> ❑Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. 40JOkay <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: Z(e /L— <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />