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SAN JOAQUIN COUNTY <br /> � .�••.oma <br /> _ y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • �:,- Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> D . . / INSPE TION T <br /> Structure Operation <br /> ❑ ❑ 1. Well constructAn PREMISE ADDRESS <br /> `FADDDRESS p RE-INSPECTION DATE <br /> El2. Cross-Conn ction 1 f a 0. cal n <br /> S re operation Manure MgKagement OWNER/P PERATOR VPHONE <br /> ❑ ❑ 3. Spread' g and Disking W 11 L m a 9_Q 7 V <br /> ❑ ❑ 4. Conc to Tanks INSPECTION TYPEP6BRO,G ELEMENT RECORD ID <br /> ❑ ❑ 5. La ning t 1 <br /> ❑ E] 6. C mposting The items below represent code violations and must be corrected: <br /> Structure Operation Bi Disposal <br /> ❑ ❑ <br /> 7/Burying with 2"of Cover 1 l( 44- to <j i!I <br /> ❑ ❑ . <br /> Approved Concrete Tank w� 00a W4,l` r 1a3 Q e <br /> ❑ 9. Removal from Premises <br /> Structure Op tion Vector Control <br /> ❑ 10. Domestic FI <br /> 1:1 EV 11. Fannia FI a <br /> ❑ 12. Larvae S f G` t <br /> ❑ 13. Pupae <br /> ❑ 14. Adult <br /> ❑ ❑ 15. Light Population t A <br /> ❑ ❑ 16. Moderate Population <br /> F'/V VCr �r Q <br /> ❑ ❑ 7. Heavy Population <br /> Structure/ Operation eding/Water <br /> ❑ ❑ 18.\JVater Trou hs <br /> ❑ 19. &ps or Bowls <br /> 20. F Storage <br /> SG <br /> cture Operation House 1 <br /> ❑ ❑ 21' FIA <br /> 11 1:122. wallsl6pilings <br /> ❑ 1 ❑ 23. Cleanin Frequena r ! <br /> MEM f; pQ. J <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 0 El 2. Cross Connection �t <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable d n <br /> 6. Covin i( i <br /> 7. Cleaning Frequency r , 'l (�, <br /> Structure Operation Walls J fit/ e, ,r' <br /> ❑ ❑ 8. Smooth/Cleanable X A- ® I n <br /> ElEl9. CleaningFrequency h t 1® <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition X <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Stora e h <br /> 13. Insect/Vermin <br /> Structure operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure operation Sewage Disposal <br /> ❑ ❑ 116. Septic System $ <br /> 11 17. Sewer X (`nj <br /> Structure Opertition Rabies Vaccination R I Y IN CTO <br /> ❑ ❑ 18. Certificate on Premise <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of_ <br />