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oAa"I" SAN JOAQUIN COUNTY • <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • �q.,- -,:•�P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �IFOIRa <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA �, INSPE C 10 DATE 0 <br /> Structure Operationr Well <br /> PREMISE ADDRSRE-INSP CTION DATE <br /> El El 1. Well Construction MISES_ <br /> ❑ ❑ 2. Cross-Connection }^ [�l'r r-\~ (-XL �ir7 j <br /> Structure Operation Manure Management OWNER/OPERQ OR PHONE <br /> ❑ ❑ 3. Spreading and Disking ' �\ + SC C <br /> =,❑ ❑ 4. Concrete Tanks IC.•�1 <br /> CTION TYPE 1 PROGRAM ELEMENT ORD IDD <br /> ❑ 5. Lagooning I LH 5q -`3 <br /> ❑ 6. Composting The items below represent code violations and must be corrected: <br /> ISN., Operation Bird Disposal ) i? <br /> 1:1 El7. Burying with 2"of Cover <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises fa \ <br /> Structure o4ration Vector Control L� <br /> ❑ 10. Domestic FIS <br /> 11. Fannia FI <br /> El ❑, 12. Larvae ' V_ ` CCIG AJ <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ;° ❑ 15. Li ht Population \ <br /> ❑ El 6. Moderate Po ulation <br /> ❑ ❑ Heavy Population <br /> Structure/ Operation F ding/Water R\ f k \ ..C-",-\ i S I <br /> ❑ ❑ 18. WaterTroughs <br /> ❑ 19. ups or Bowls < 6 IMIS <br /> ❑ ❑ 20. Nd Storage i <br /> Structure Operation Houses <br /> 1:1El21. Floors <br /> L'4 <br /> 11 11 <br /> 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Frequencvti <br /> Structure Operation Water Well .\ <br /> ❑ ❑ 1. Well Construction �� I <br /> ❑ ❑ 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to Sewer 9 <br /> El 1:14. Drain C�;' : L -) <br /> ❑ ❑ 5. Smooth/Cleanable ^� <br /> E] El 6. Covin lI ��G�]1 ~/ <br /> ❑ ❑ 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> 11. Sanita ion <br /> Structure Operation Food",A <br /> ❑ ❑ 12. Storage <br /> ❑ ❑ 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other ? �, 1 <br /> Structure Operation Sewage Disposal �I L t <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer l `� <br /> Structure Operation Rabies Vaccinations RECEIVED BY, IN <br /> C s <br /> ❑ ❑ 18. Certificate on Premises W i <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of_ <br />