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os( <br />CiLdc'‘ <br />A Div7sion or San foaquin County Health Care 5ervloas <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department or the qualified contractor and send to: <br />San Joaquin County <br />bsct. 4)_Qc0-,G06 ,-, Public Health Services <br />Environmental Health Division <br />k Recreational Health Program <br />304 East Weber Avenue, Third Floor <br />Stockton, CA 95202 <br />PUB' LIC fteALTH SERVtlitS <br /> <br />O. '' ' • .0 -.0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer cklicSirss,C7: <br /> <br />Arvac3 .\ 0. <br />304 East Weber Avenue, Third Floor • Stockton, CA 95_02 ,A . , <br />209/468-3420 -\ <br />sNu" <br />VERIFICATION OF COMPLIANCE WITH CALIF, 'TIT AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />Site address of pool(s) \ 13 D0' GL SC <br /> <br />C i <br /> <br />(k) <br /> <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the sie <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 />Signature <br />Address <br />City St Zip <br />Telephone ( <br />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 />Date