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o°a�Iy SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> q.. ::..•;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFORlt <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPE ION DATF <br /> Structure Operation Water Well 7ZI,6 <br /> 1:1 El 1. Well Construction PREMISE ADDRESS RE-I SPECTtON DATE <br /> ❑ ❑ 2. <br /> Cross-Connection G <br /> Structure Operation Manure Managemeny OWNS OPERATOR P E <br /> 1:1 ❑ 3. Spreading and Diski g R ( v6 I-- <br /> ❑ ❑ 4. Concrete Tanks INS TION PE PROGRAM ELEMENT RECORDD IDD <br /> 1:1 ❑ 5. Lagooning ''77 <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Bu in wit 'of Cover ` <br /> ❑ 1 ❑ 8. Approved ioncrete Tank <br /> ❑ ❑ 9. Remova rom Premises <br /> Structure Operation Vector ntrol <br /> ❑ ❑ 10. Do estic FI <br /> El 11. F46nia FI ,® 3 <br /> ❑ ❑ 12. rvae y <br /> ❑ ❑ 13./Pupae <br /> ❑ ❑ 1j Adult <br /> ❑ ❑ 5. Light Population <br /> ❑ ❑ f 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operay6n Feeding/water <br /> ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> El Li 20. Food Storage <br /> structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ 1 22. Walls/Ceilings -- <br /> ❑ 23. Cleaning Frequency <br /> Structure Operatio Water Well <br /> ❑ ❑ Well Construction 44.- a <br /> Connection <br /> Structure Operati FIoo <br /> 0 El rl Graded toSewer <br /> El El . Drain <br /> ❑ ❑ Smooth/Cleanable <br /> El El 6. Covin <br /> El 7.SAgaping Frequency <br /> Structure Operation w s <br /> ❑ ❑ mooth/Cleanable <br /> ❑ ❑ leaning Frequency <br /> Structure Operation Cag <br /> ❑ ❑ . Condition <br /> 11. Sanitation <br /> Structure Operation Oo <br /> ❑ ❑ rage <br /> 13. insect/Vermin <br /> Structure operation Imal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 1 <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 6. Septic S stem <br /> ❑ ❑ <br /> Structure Operatiqn Rabies Vaccinati RECEIV Y (NSP CTOR <br /> ❑ ❑ remises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />