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S A N J O A Q U I N Environmental Health Department COUNTY fi Greatness grows her,. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: fj L-C-6to a C,r PR#: LOCATION: ID actq�L Ott YZ MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: qCf Z 6 Date of Inspection: Type of Housing Unit: Z Single Family Dwelling ❑ Mobile Home ElOther: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: ��,�✓ (� HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water, l tay ❑Need§Repair* Approved electrical power and gas fuel being supplied to Unit. Okay ❑Need a air* Heater maintained in functioning and safe manner(No space/portable heaters). Okay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. BOkay ❑Ne ds Repair* All rooms are clean and sanitary.No insect/rodent infestations present. Okay Ne Els Repair* All appliances(stove,water heaters,air conditioning units,heaters)are Okay properly vented,strapped and are maintained in a safe,working order. ❑Ne ds Repair* All smoke and carbon monoxide detectors are present and tested to be shown okay in workingorder. ElN4eds Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay ❑N eds Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ElN Qds Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay ❑N eds 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 Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. okay ❑Nefeds 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 ❑N eds Repair* Propane tank has barrier protection and"No Smoking"signage. Okay ❑N eds Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑N eds Repair* The electrical panel is covered and protected from tampering. El N Okay eds Repair* The gas fuel connection is as approved and safe. Okay ❑N 'ds Repair* There are no insect or rodent infestations. k ElR N ds Re air' JX The sewage system is functioning,with no surfacing wastewater or backup. Okay ❑N6eds 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 inspect% the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com