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SAN JOAQUIN COUNTY <br />r y ENVIRONMENTAL HEALTH DEPARTMENT <br />::.. 600 East Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: wwwsjgov.org/ehd <br />�rFOR <br />VECTOR CONTROL INSPECTION FORM <br />Structure <br />Operation <br />Water Well <br />DBA <br />INSPECTION DATE <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE ADDRESS <br />RE-INSPECTI N DATE <br />❑ ❑ 2. Cross -Connection <br />Structure <br />Operation <br />Manure Management <br />OWNER/OPERATOR <br />PHONE <br />5' - <br />❑ ❑ 3. Spreading and Disking <br />❑ <br />❑ <br />4. Concrete Tanks <br />lNSPEcTiqN TYPE <br />PROGRAM ELEMENT <br />RECORD ID <br />5. Lagooning <br />❑ <br />❑ <br />6. Composting <br />The items below <br />epresent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />❑ ❑ 7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. ADDroved Concrete Tank <br />❑ ❑ 9. Removal from Premises <br />Structure <br />Operation <br />Vector Control <br />❑ ❑ 10. Domestic FI <br />11 <br />El <br />11. Fannia FI <br />c <br />❑ ❑ 12. Larvae <br />❑ <br />❑ <br />13. Pupae <br />❑ ❑ 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />LZ <br />❑ ❑ 16. Moderate Population <br />❑ <br />❑ <br />17. Heavy Population <br />I f <br />S® <br />structure Operation Feeding/Water <br />❑ <br />❑ <br />18. Water Troughs <br />❑ ❑ 19. Cu s or Bowls <br />20. Food Storage_ <br />_ <br />Structure Operation Houses <br />❑ <br />❑ <br />1 21. Floors <br />J <br />e <br />❑ ❑ 1 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleanin Fr uen <br />NEEMEME <br />Structure <br />Operation <br />Water Well <br />JIB, <br />L®y' <br />❑ ❑ 1. Well Construction <br />2. Cross Connection <br />Structure Operation Floors <br />110 <br />❑ <br />3. Properly Graded to Sewer <br />❑ ❑ 4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />❑ 6. Covin <br />❑ <br />7. Cleaning Frequency <br />Structure Operation Walls <br />❑ <br />❑ <br />8. Smooth/Cleanable <br />❑ ❑1 9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />❑ ❑ 10. Condition <br />11. Sanitation <br />Structure Operation Food <br />❑rn <br />12. Stora e <br />El El 13. Insect/Vermin <br />Structure <br />Animal DIS osal <br />❑14. Removal from Premises <br />15. Other <br />structure Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structure <br />OperAtion <br />Rabies Vaccination <br />RECEIVED ay <br />INSPEC R <br />❑ ❑ 18. Certificate on Premises <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 12/04/08 (5171- <br />Page f of <br />