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PQurH SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> a.. .:;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> <<F ORN <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INS P CT ON D TE <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDR SS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Mana em t OWNER/OPERATOR Cl PHONE <br /> ❑ ❑ 3. Spreading and Di 'ng /" C_ J S --7 f 7 <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ElE] 5. Lagooning gZ16 <br /> 13 El 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispo I <br /> ❑ ❑ 7. Buvino ith 2°of Cover <br /> ❑ ❑ 8. Approv6d Concrete Tank <br /> s <br /> ❑ ❑ 9. Rem val from Premises <br /> Structure Operation VeCt9f Control <br /> ❑ ❑ 10. omestic FI <br /> El 11 Z Fannia FI <br /> ❑ ❑ . Larvae ®� <br /> ❑ ❑ A3. Pupae <br /> ❑ ❑ 1 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ 11 17. Heavy Population <br /> Structure o .tion Feeding/water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cu s or Bowls <br /> 20. Food Storage <br /> Structu Operation Houses <br /> ❑ ❑ 1 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> 665- ❑ 23. Cleaning Frequency <br /> Structure Operation ate 1 -- <br /> ❑ ❑ Well Construction <br /> El ED] s Connection <br /> Structure Operation F <br /> El El Properly Graded to Sewer 011 <br /> ❑ ❑ Drain �' 9 <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El D 7. Cleaning Frequency <br /> Structure Operation Wells <br /> ❑ ❑ 8. Smooth/Cleanable ` <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operatic CgeS <br /> ❑ ❑ A,, . Condition <br /> 1. Sanitation <br /> Structure Operation <br /> ❑ ❑ tor. e <br /> El EI 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ <br /> Septic System <br /> ❑ ❑ <br /> Structure Opereti RableaYaecirMti6n R VED BY <br /> INSPECTOR <br /> ❑ ❑ ertificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page t of <br />