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Site address of pool(s) 820 NORTH LOWER SACRAMENTO ROAD <br />City LODI , CA 95242 <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />1 SWIMMING POOL <br />I verify that I am the owner/home owner association president/legally responsible person for the <br />above named pool(s) and that I had the pool(s) inspected for compliance with Section 116049.1 <br />(a-f) of the California Health and Safety Code. <br />Print name <br />Signatur <br />Address <br />City LODI <br />Date 6/1/98 <br />Y TREET SUITE B <br />St CA Zip 95240 <br />Telephone (209 ) 369-4701 <br />El There is no pool light in this/these pool(s). Indicating there is no pool light means there <br />is no light fixture, light casing, or recessed light niche, whether working or not <br />working, within the confines of the pool shell. <br />YES <br />- PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION " <br />juN I 4 Karen Furst, M.D., M.P.H., Health Officer• -2 PH : 0 <br />304 East Weber Avenue, Third Floor• Stockton,-CA 95202 <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department and send to: <br />San Joaquin County <br />Public Health Services <br />Environmental Health Division <br />Recreational Health Program <br />304 East Weber Avenue, Third Floor <br />Stockton, CA 95202 <br />A Division of San Joaquin County Health Care Services