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Site address of pool(s) <br />Number of swimming poo/S,^spa pools, wagr s ols or specie/ purpose, pools at tlae site <br />C7-4, <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 />Piint name `R, atc_cr Kflt,E1) Date <br />3 fa) trn- <br />Signature rb RSAA-W,Al <br />Address caw / aokb 6r1P-IKr.Itb 945 grOd .,1411T-T° <br />City SALO AA.% ems • St Ci9 zip _.2.570- <br />Telephone 6_1.) 75T-- 47 9.7 <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 <br />working, within the confines of the pool shell. <br />, 03/29/2000 13:01 12097544797 <br />PAGE 02 <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRON?vENTAL, HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 EASE 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 /> gmmaidommisommoimmimirm—*—' <br />Please attach a copy of the completed and signed inspection permit or report front 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 Div;sion cif San Joaquin County Care Scriicts