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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> c� :.- ;�• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �IFpR <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 2 9 <br /> Structure Operation Manure Managepient OWNER/OPERATO PHONE <br /> 11 El3. Spreading and isking 01yee -3e4-- 9 <br /> ❑ ❑ 4. Concrete Ta s INSRECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagoonin -'I'V C Y <br /> ❑ ❑ 6. ComposAg The items below represent code violations and must be corrected: <br /> Structure Operation Bird Di§6osal <br /> ❑ ❑ 7. Bu ng with 2"of Cover <br /> Cl ❑ 8. A roved Concrete Tank <br /> ❑ ❑ 9.Aernoval from Premises <br /> Structure Operation y6ctor Control <br /> ❑ ❑ 10. Domestic FI <br /> 11 A 11. Fannia FI <br /> ❑ ❑ 12. Larvae ~ <br /> ❑ ❑ 13. Pupae <br /> ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation FeedingMater <br /> ❑ ❑ 18. Water Troughs - f, <br /> ❑ ❑ 19. cups or Bowls , <br /> EV 0 20. Food Storage <br /> strupture Operation Houses <br /> ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings 9 <br /> ❑ ❑ 1 23. Cleanin Fr uenc <br /> Structure Operation _WatffjU9W <br /> ❑ ❑ 1. Well Construction �t <br /> 11 EIV s Connection <br /> Structure Operation Flo <br /> ❑ ❑ -3.-Propedy Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ . Smooth/Cleanable <br /> ❑ ❑ 6. Covin <br /> 11 ❑ 7. Cleaning Frequency <br /> Structure Operatic ails <br /> ❑ ❑ Smooth/Cleanable <br /> ❑ ❑ 9.Jqw2ningFrequency <br /> Structure Operation ages <br /> ❑ ❑ . Condition <br /> El 1 tation <br /> Structure OperationF <br /> ❑ ❑ <br /> Storage <br /> StructureOperation Animal Dis <br /> ❑ El . Removal from Premises <br /> ❑ ❑ 15. Ot <br /> Structure Operation ewage Dis <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ ewer <br /> Structure OPer*t1Aq& Rabies VaCd ualtltW RECEIV BY INSPECTOR <br /> r <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page l of� <br />