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Print name "xi& eede 4 Pflil6-C <br />Signature., <br />Address <br />Date <br />City 6tac ttO 1/1 <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <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 />City ...5A/JT/1 ittig St (:14 ) zip 9.5----57 <br /> <br />Telephone ( 1/4/1) c;k7 47/ -42,14? <br />ri 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 f)iviitoll Of Joaquin Can In V I•le. a l Ca IT r v