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S A N�J 0 A 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 <br /> FACILITY NAME: )JP ? / �'u' PR#: <br /> LOCATION.-4/l1 { 1 r '�;t_ 04 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unite „;? `j ,U `Date of Inspection: xG � <br /> Type of Housing Unit: [D'Single Family Dwelling ❑Mobile Home ❑Other: <br /> #Employees in Unit: iDate Unit First Built or Installed: <br /> Electrical Power Provided By: :- �� �. Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> [INeeds Repair' <br /> Approved electrical power and gas fuel being supplied to Unit. E�Okay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). kay <br /> ❑Needs Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present, Elkay <br /> Needk Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 90kay <br /> properlyvented 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 ay <br /> in working order. ❑Ne ds Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), ay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). E�Okay <br /> ❑Needs Repai50 <br /> r' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ay <br /> ❑Needs air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ay <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. kay <br /> ❑Needs E air' <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, kay <br /> ❑Needs air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ay <br /> ❑Needs a air* <br /> Propane tank has barrier protection and'No Smoking"signage. &JOkay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly, [Xay /I G- A_L/ ,J U iL- LL- <br /> ❑NEYeds Repair* - _ Ij )t' <br /> The electrical panel is covered and protected from tampering. kay <br /> ElNeeds Repair* <br /> Ejoka <br /> The gas fuel connection is as approved and safe. ElNeeds Re air* <br /> There are no insect or rodent infestations. G;Okay <br /> ElNeeds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup, 20kay <br /> ElNeeds 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: �IL.GJ (� <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 J www.sjcehd.corn <br />