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ot`auI" SAN JOAQUIN COUNTY <br />E RONMENTAL HEALTH DEPARTMENT <br />Y. <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 />EHD 40-06 12/04/08 <br />Page ! of _ <br />mommommmm <br />DBA <br />INSPECTION DATE <br />Structure <br />Operation <br />If /'/` it <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE ADDRESS <br />RE -INSPECTION DATE <br />❑ <br />❑ <br />2. Cross -Connection <br />Structure <br />Operation <br />Manure Management <br />OWN RfOPERATOR <br />PHONE <br />❑ <br />❑ <br />3. Spreading and Disking <br />a 1 <br />-1 <br />❑ <br />❑ <br />4. Concrete Tanks <br />INP TION TYPE <br />PROGRAM ELEMENT <br />RECORD ID _ <br />❑ <br />5. Lagooning <br />L15 <br />q o 5..S <br />❑ <br />❑ <br />6. Composting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />❑ <br />❑ <br />7. Burying with 2" of Cover <br />t` <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />❑ <br />❑ <br />9. Removal from Premises <br />Structure <br />operation <br />Vector Control <br />❑ <br />❑ <br />10. Domestic FI <br />i <br />11. Fannia FI <br />❑ <br />❑ <br />12. Larvae <br />❑ <br />❑ <br />13. Pupae <br />El <br />14. Adult <br />F, f <br />❑ <br />❑ <br />15. Light Population <br />❑ <br />❑ <br />16. Moderate Population <br />❑ <br />❑ <br />17. Heavy Population <br />Structure <br />Operation <br />FeedinglWater <br />®' <br />❑ <br />❑ <br />18. WaterTrou hs <br />❑ <br />❑ <br />19. Cups or Bowls <br />20. Food Storage <br />Structure <br />Operation <br />Houses <br />1C e <br />❑ <br />❑ <br />21. Floors <br />❑ <br />❑ <br />22. Walis/Ceilin s <br />❑ <br />❑ <br />23. Cleaning Fr uenc <br />4 <br />bt <br />cture <br />Operation <br />Water Well <br />❑ <br />1. Well Construction <br />a S <br />2. Cross Connection <br />Structu <br />Operation <br />Floors <br />❑ <br />3. Properly Graded to ewer <br />❑ <br />❑ <br />4. Drain <br />❑ <br />❑ <br />5. Smooth/Clea ble <br />6. Covin <br />7. Cleanina re uenc <br />Structure <br />on <br />Walls <br />a <br />❑ <br />❑ <br />8. Sm th/Cieanable <br />❑ <br />❑ <br />9. C ninqFrequency <br />Structure <br />Operation <br />Coes <br />❑ <br />❑ <br />A. Condition <br />11 <br />11 <br />11. Sanitation <br />Structure <br />Operatic <br />F <br />❑ <br />❑ <br />12. S rage <br />El <br />13. Ins ermin <br />structure <br />Op tion <br />Animal is al <br />❑ <br />❑ <br />14. Remo from Premises <br />❑ <br />❑ <br />15. Other <br />Structure <br />Operation <br />Sewage DIS oral <br />❑ <br />❑ <br />16. Se tic S t <br />El <br />❑ <br />17. Sewer <br />Structure <br />Operation <br />I Rabies Vaccination <br />RECEIVED BY <br />INSPECT <br />❑ <br />❑ <br />18. Certificate on Premises <br />VECTOR CONTROL INSPECTION FORM - <br />EHD 40-06 12/04/08 <br />Page ! of _ <br />