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t'q"'" SAN JOAQUIN COUNTY <br /> �O '••.COG <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N X <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> . �q.; :•..;P <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �iFORa <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTJON DATE <br /> Structure Operation Water Well 03 <br /> PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 1. Well Construction � <br /> ❑ ❑ 2. Cross-Connection ��� <br /> Structure Operation Manure Mana @m@ OWNER/OPERATOR /PHONE <br /> ❑ ❑ 3. Spreading and Di ing Com_ C ) d.- .?/ <br /> ❑ ❑ 4. Concrete Tanks INSPE TION TYPE PROGRAM ELEMENT RECORD ID <br /> El E] 5. Lagooning di✓ / � _S- <br /> ❑ E] 6. Composting/ The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispo al <br /> ❑ ❑ 7. Bu in ith 2°of Cover , ^� <br /> ❑ ❑ 8. Appro ed Concrete Tank <br /> ❑ ❑ 9. Re val from Premises <br /> Structure Operation Vect r Control <br /> ❑ ❑ 10. omestic FI <br /> El 0 1 Fannia Fly <br /> El El2. Larvae �y <br /> El El13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Li ht Population <br /> ❑ 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure O ration Feeding/Water s t <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structu Operation Houses <br /> ❑ 21. Floors a-. <br /> ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Frequency <br /> ^ Structure Operationater W <br /> ❑ ❑ 1. Well Construction <br /> doss Connection <br /> Structure Operation Fl y <br /> 3. Pro erl Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable f� <br /> 6. Covin -- <br /> El 0 7.aeaning Frequency <br /> Structure Operation <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9.-Cleaning Frequency <br /> 4 <br /> Structure Operation C ge <br /> ❑ ❑ 10t <br /> Condition <br /> 1:1 El ation <br /> Structure Operatio❑ ❑ eEl Structure OperatioDIS OS❑ ❑ val from Premises <br /> ❑ ❑ 5. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ AIAIW Septic System <br /> ❑ ❑ <br /> Structure Operation Rabies Vaccin_aUOW R CEI ® INSPECTOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page,of <br />