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S A N J 0 A Q U I N Environmental Health Department <br /> COUNTY <br /> Lr,=0;`'r Greufness grows h <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: p I—e 4Q PR#: <br /> LOCATION: `� � Jf­MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: G <br /> Type of Housing Unit: R Single Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION �r <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. keRepair* <br /> ay <br /> ❑N Re air' <br /> Approved electrical power and gas fuel being supplied to Unit. ay <br /> El <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Okay <br /> ❑Nee <br /> 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 jn0kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Neeq5 Repair' <br /> All smoke and carbon monoxide detectors are present and tested to be shown 4nOkay <br /> in working order. ❑Needs.Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). [20kay <br /> ❑Ne Repair* <br /> All plumbing in safe,working order(no leaks,property maintained). Okay <br /> ❑Nee Re air' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑Nee Re air* <br /> All Floors,walls,ceilings are free from holes,are not sagging or buckling,have 7fOkay <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. Oka <br /> [:1 Nee a air' <br /> Ok y <br /> Exteriors r+g is maintained with no loose plaster,peeling paint,holes,etc. ❑ e Re air' <br /> O <br /> Stairways are safe with no rotting,deteriorating,or loose parts. El Ne Re air' <br /> ka <br /> Propane tank has bamer protection and'No Smoking'signage. O <br /> ❑Nee a air' <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Repair* <br /> trical <br /> Ok y <br /> The elec pane!is covered and protected from tampering. ❑Nee Re air* <br /> Okay <br /> The gas fuel connection is as approved and safe. ❑ e Re air' <br /> Oka <br /> There are no insect or rodent infestations. ❑Nee a air' <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑Needs Re air* <br /> *Needs Repair:Please specify 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 <br /> DATE TITLE y <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />