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�pAQU1N .Co SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 --a <br /> y 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> .. P• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> O ® p� ®TRp� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBAKe <br /> li®CTIO DATE <br /> O`S <br /> Structure Operation Water Well V\1q_TPr3' CS <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 13700t <br /> Structure Operation Manure Management OWNERIOPERATOR PHONE a <br /> El E] 3. Spreading and Disking Z Q - C�Z <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROG&M ELEMENT RECCORD ID <br /> ❑ ❑ 5. Lagooning 44 S P ®JS LIA06S& <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> El F17. Bu in with 2"of Cover v t �'OW. s <br /> ❑ ❑ 8. Approved Concrete Tank l <br /> ❑ ❑ 9. Removal from Premises <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae O el� <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 1 15. Light Population <br /> ❑ ❑ 16. Moderate Population M"l <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Frequency <br /> ME= EMEMEEM <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> El 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 1 8. Smooth/Cleanabie <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> El El 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> El n 13. insect/vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY INSPE TOR <br /> ❑ ❑ 18. Certificate on Premises w <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page f of <br />