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011,N1 <br /> .4 . c S A N J 0 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: 7Q c �j_t, "r PR#: <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: KSingle Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: Y �� <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. QOkay <br /> ❑NVee <br /> ir' <br /> Approved electrical power and gas fuel being supplied to Unit. <br /> ❑ ir'Heater maintained in functioning and safe manner(No space/portable heaters). <br /> ❑Needs a air' <br /> Doors and windows are accessible/operable to allow for safe exiting. PClkay <br /> ❑Neeod Repair* <br /> All rooms are clean and sanitary.No insectlrodent infestations present. Okay <br /> ❑Nee Re air' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Neeo Repair' <br /> All smoke and carbon monoxide detectors are present and tested to be shown ZOkay <br /> in working order. ❑Nee0a 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. Okay <br /> ❑NeSgt Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Okay <br /> no water leaks and are clean and in good condition. I ❑Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ❑Nee Re air` <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ElNe a air' <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. okay <br /> ❑Ne Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> [INe Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑Need a air' <br /> The gas fuel connection is as approved and safe. 1�30kay <br /> ❑Ne Re air` <br /> There are no insect or rodent infestations. Okay <br /> ElNee a air' <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <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 1 have inspected the ab ve noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNE <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue ( Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />