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AgaU"11" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd <br /> O¢� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DAT <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well construction PREMISE ADDRESS �-. RE-INSPECTION DATE <br /> ElEI2. Cross-Connection 3/,dr <br /> Structure Operation Manure ManagemeAt OWN OPERATOR V PHONE <br /> 1:1 El3. Spreading and Di ing f �),g r(� <br /> ❑ ❑ 4. Concrete Tank INSP TION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning -� z/4/�� 9 CX903 <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispofial <br /> ❑ ❑ 7. Bu in ith 2'of Cover y P' <br /> ❑ ❑ <br /> 8' Apprqkd Concrete Tank <br /> El 1:19. Re oval from Premises <br /> Structure Operation Vec r Control <br /> ❑ ❑ 10 Domestic FI <br /> El 1f. Fannia FI <br /> 13 2. Larvae 'l2 <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population Of <br /> r <br /> ❑ EY 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure O eration Feeding/Water <br /> 1:11:118. Water Trou hs <br /> ❑ 1 ❑ 19. Cups or Bowls <br /> EI 171 20. Food Storage <br /> Struct Operation Houses <br /> ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings .- <br /> ❑ ❑ 23. Cleaning Fre uenc <br /> Structure operation Water%EW <br /> ❑ ❑ 1. Well Construction <br /> s Connection <br /> Structure Operatic FI or <br /> E:I El Properly Graded to Sewer <br /> ❑ ❑ Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El m 6. Covin <br /> 7 anin Fre uenc <br /> Structure Operation W s <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ P . Cleaning Frequency <br /> Structure Operation 8 es <br /> El El 10. Condition <br /> El <br /> IEEII two 11 itation <br /> Structure Operation Itood <br /> ❑ ❑ 12. Storage <br /> 3. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ <br /> Structure Operati n Sewage Disg9sal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RE D BY INSPECTOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 Page of <br />