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SAN J OAQ U I N EEnvirOnmental 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: ``\ PRrr <br /> LOCATION: `P- t�((y� cr(� MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification num 4er of unit:Z �, M m ate of Inspection: <br /> Type of Housing Unit: ingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: 4 C� Gas Provided by: <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Need Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ Nee Re air* <br /> Heater maintained in functioning and safe manner(No space/portable Okay <br /> heaters). ❑ Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting, okay <br /> -- ----- ------ - —--- ee Repair* ---- ----------All-ooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> _ ❑ Needs Repair' <br /> All appliances(stove,water heaters air conditioning units,heaters)are 210kay <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 kay <br /> in working order, ❑ Need Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> _ ❑ Needs Repair- <br /> All <br /> e air*All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑ Nee epaair* ------ ----- — -- - <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Need Re air' <br /> All floors,walls.ceilings are free from holes,are not sagging or buckling,have ZOkay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Z Comments _ <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> [I Needs,,Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> — _ ❑ Neeys -- <br /> Stairways are safe with no rotting,deteriorating,or loose parts. DzOkay <br /> --- ❑ Neeos Repair* - - -- <br /> Propane tank has barrier protection and"No Smoking"signage. O Ry <br /> _ ❑ Nee Repair* _ <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee5K Repair <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑ Nee s Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Nee Re air" _ <br /> There are no insect or rodent infestations. Okay <br /> _ ❑ Ne4s Repair' _ <br /> The sewage system is functioning,with no surfacing wastewater or backup Okay <br /> ElNeeds Repair* <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 ins cted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED I <br /> t <br /> 1 1,71 <br /> NAME DATE TITLE <br /> 18 8 E Hazelt VveNue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />