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Site address of pool(s) <br /> <br />67,746 __6 6.,B Mc42644/3 a.41c.E_ <br /> <br />City ,5ka <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />pcxt- I —54 <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 />6E666 , ciM MOO Date q ) CfS' <br />9tiv > 63q7Zq do <br />64-04- md-o14 z-A) <br />C ity S /61k/--TO ki St CA Zip CtS Z ( 2-- <br />Telephone ( 70(1 ) 3 61 3 <br />E 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 />Print name <br />Signature <br />Address <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