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SAN JOAQUIN COUNTY <br />y2 <br />ENS ONMENTAL HEALTH DEPARTMEP <br />< <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />VECTOR CONTROL INSPECTION FORM <br />P 0 u L TRY RANCH DBA <br />INSPECTION DATE <br />Structure Operation <br />Water Well <br />❑ ❑ <br />1. Well Construction -PREMISEIADDRLISS <br />REINSPECTION DATE <br />❑ ❑ <br />2. Cross-ConnectionmL, A <br />Structure Operation <br />Manure Management O EWOPERATOR <br />PHONE <br />❑ ❑ <br />3. Spreading and Disking <br />Z:?- <br />❑ ❑ <br />4. Concrete Tanks INSPE ION TYPE <br />PRO RAM ELEMENT <br />RECORD ID <br />❑ ❑ <br />5. Lagooning <br />❑ ❑ <br />6. Composting The items below represent Code violations and must be Corrected: <br />Structure Operation <br />Bird Disposal <br />❑ ❑ <br />7. Burying with 2" of Cover <br />❑ ❑ <br />8. Approved Concrete Tank <br />❑ ❑ <br />9. Removal from Premises b-- <br />Structure Operation <br />Vector Control <br />❑ ❑ <br />10. Domestic Fl <br />❑ ❑ <br />11. Fannia Fl <br />❑ <br />12. Larvae > <br />❑ ❑ <br />13. Pupae <br />❑ 0 <br />14. Adult <br />❑ ❑ <br />15. Light Population <br />❑ El <br />16. Moderate Population <br />❑ 0 <br />17. Heavy Population <br />Structure Operation <br />Feeding/Water <br />❑ ❑ <br />18. Water Troughs <br />❑ ❑ <br />19. Cups or Bowls <br />❑ D <br />20. Food Storage <br />Structure Operation <br />Houses <br />❑ ❑ <br />21. Floors <br />❑ ❑ <br />22. Walls/Ceilings <br />❑ <br />23. Cleaning Fre uenc <br />KENNEL <br />Struct a Operation <br />Water Well <br />❑ 111. <br />Well Construction <br />❑ ❑ <br />2. Cross Connection <br />Structure Operation <br />Floors <br />❑ ❑ <br />3. Properly Graded to <br />❑ ❑ <br />4. Drain <br />❑ <br />5. Smooth/Clea le <br />❑ <br />6. Covin <br />❑ ❑ <br />7. Cleanin re uenc <br />Structure Operatio <br />Walls <br />❑ ❑ <br />8. Sma h/Cleanable <br />El El <br />. C1 nin Frequency <br />Structure operation <br />a s <br />El El <br />Condition <br />❑ ❑ <br />1. anitation <br />Structure Operation <br />FOO <br />❑ ❑ <br />12. St a e <br />❑ <br />13. Inse VVermin <br />Structure Ope ion <br />Animal Nposal <br />❑ <br />14. Rerno from Premises <br />❑ <br />15. Other <br />Operation <br />Sewage Dispos <br />❑ <br />16. Se tic S ste <br />N <br />17. Sewer <br />Operation <br />Rabies Vaccination RECEIVED INSPECTOR <br />❑ <br />18. Certificate on Premises <br />EHD 40-06 6/30/2005 <br />Page 4 of ___ - <br />