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PUBLIC �ALTH SERVES <br />SAN JOAQUN COUNTY <br />(4k <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer., <br />304 East Weber Avenue, Third Floor • Stockton, CA 9920'2�{ 11` 7 <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a -f) <br />Site address ofpool(s)'JSO (l . Unto,-% Qui . <br />City (Ylari}CA. <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />I verify that I am the ownerihome 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 G -;Q; Ear -p Date (o - 1`1 - qq <br />Signature Ea�� <br />Address 3SC> (-\. Union CA. ;`2lD <br />City OAant-ecct St CA Zip C�5 33 1 <br />Telephone( X09 ) $�3-y�83' D�9 c133Uwori� <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 />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 />Public Health Services <br />Environmental Health Division <br />Recreational Health Program <br />304 East Weber Avenue, Third Floor <br />Stockton, CA 95202 <br />A Dr:;siun or pan juaquin County Health Care Services <br />