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SA NJ 0A Q U IN 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 tA <br /> FACILITY NAME: L' ;) h.Z 1011i" C,1. 0 PR#: <br /> LOCATION: -' �� LltL.r�t� �� -!�". �' MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification numper of unit:L� tj �/�if'if %�_Date of Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑Cther: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: f� <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑Needs Repair* <br /> E�MaApproved electrical power and gas fuel being supplied to Unit. <br /> ❑Needs Repair' <br /> air" <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). El Needs[eds,R <br /> Re air` <br /> Doors and windows are accessible/operable to allow for safe exiting. [46kay <br /> ❑Needs a air' <br /> All rooms are clean and sanitary.No insectlrodent infestations present. kay <br /> ❑Needs,Re air' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <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. ❑Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), Ej� `ay <br /> ❑Needs Pe pair* <br /> All plumbing in safe,working order(no leaks,properly maintained). ' ay <br /> ❑Needs a air' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑Needs air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 5Kay <br /> no water leaks and are clean and in good condition. ❑Needs Repair' <br /> Exterior Checklist I Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. kay <br /> ❑Needs a air" <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, E90kay <br /> ElNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. kay <br /> ElNeeds a air'&Ma <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑ R Needs Repair' <br /> The electrical panel is covered and protected from tampering. ay <br /> ❑Needs air' <br /> The gas fuel connection is as approved and safe. ❑ R Needs a air" <br /> There are no insect or rodent infestations. ay <br /> ❑Needs air' <br /> The sewage system is functioning,with no surfacing wastewater or backup, Ego'kay <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', r <br /> 11 <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />