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Site address of pool(s) 1540 Mosaic Way <br />City Stockton, Ca. 95207 <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />3 Swimming Pools & 1 Spa. <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 --/t9 (...!7:-- f(1 Date -Ay <br /> <br />r.JVc./ <br />\r; <br />Signature <br />Address <br />City St Zip <br />Telephone (r20 ) 3 7 <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 />IIP <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <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