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Signatiire c,...C:)-aS2._ (A, <br />AddressR0?a-k .2.A0C1_ <br />Cl'ty 5rri C St <br />Telephone ) -b$ 77 se9p <br />DB-25-195E 08:36PN FRCIr To 875804i P.0! <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />- ' i:P -.7 Kar4ii Piust, M.D., MPH., Health Officer ' <br />.304 East Weber Avenue, Third Floor • Stockton, CA 95202 4,... ..-: oi."11$ <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORP.ZIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />i <br /> <br />Site address of pools) 5S-- I I i•Dvekl:Tro-c_1*--- lA51) , <br /> <br />City —171 .C4 3 7 <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />! verifyjthat I am the owner/borne 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-0 of 'the California Health and Safety Code. , Co Ari- 0 9z7 <br />5--3/-9E3 <br />0 There is no pool light in this/these pool(s). Indica abere is no pool light nueens_theri is. no light fixture, light casing, or recessed light niche,NA-ether-working-orb-VC working, within the confines of the pool shell. <br />Please attach a copy of the completed and signed inspection permit or report from the iocai 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 aYision of San Joaqutm C.7.:ounty Health Care fervicc,:. <br />TCHHL P. <br />pr jnt ) e Date <br /> J