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r Q ,® oo SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA .'MENT a 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd VECTOR CONTROL INSPECTION FORM P O U L T R Y RANCH DBAINSPECTION DATE re StructuOperation Water Well E W)r '. C, ❑ ❑ 1. Well Construction PREMISE ADDRESS i REINSPECTION DATE ❑ 2. Cross-Connection t;o 1 Structure Operation Manure Management OWNER/OPERATOR PHONE ❑ ❑ 3. Spreading and Disking 'c vj ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID ❑ ❑ 5. Lagooning 't VA 4 ❑ ❑ 6. Composting The items below represent code violations and must be corrected: Structure Operation Bird Disposal ❑ ❑ 7. Burying with 2"of Cover ❑ ❑ 8. Approved Concrete Tank ❑ ❑ 9. Removal from Premises Structure Operation Vector Control ❑ ❑ 10. Domestic Fl ❑ 0 11. Fannia Flyq El 12. Larvae 64t:` ❑ ❑ 13. Pu ae ❑ El 14. Adult 11 ❑ 15. Light Population ❑ El 16. Moderate Population ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water w t9 ❑ ❑ 18. Water Troughs ❑ ❑ 19. Cu2s or Bowls \vii t ❑ 0 20. Food Stora e p Structure Operation Houses ❑ ❑ 21. Floors ❑ ❑ 22. Walls/Ceilings e,ido ❑ ❑ 23. Cleaning Frequency KENNEL v 'a- Structure Operation Water Well 1. Well Construction t er ❑ El 2. Cross Connection 1 Structure Operation Floors "'t l V, ❑ ❑ 3. Properly Graded to y ❑ ❑ 4. Drain t t ❑ ❑ 5. Smooth/Cleanable El El 6. Covin -4 ❑ ❑ 7. Cleaning Frequencyg` Structure Operation Walls CI-ti ` ❑ ❑ 8. Smooth/Cleanable ❑ El 9. Cleaning Frequency Structure Operation Cages ` ❑ El 10. Condition ❑ ❑ 11. Sanitation Structure Operation Food ❑ ❑ 12. Storage 9 ❑ ❑ 13. Insect/Vermin Structure Operation Animal Disposal ❑ ❑ 14. Removal from Premises ❑ ❑ 15. Other Structure Operation Sewage Disposal ❑ ❑ 16. Septic System ❑ ❑ 17. Sewer Structure Operation Rabies Vaccination RECEIVED BY INS OR ❑ ❑ 18. Certificate on Premises EHD 40-06 6/30/2005 Page I of !