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Site address of pool(s) <br /> 1 ,-(O1 iloe• ((s--id -re (.5(qk <br />City .c <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />( (,) p o ‘( <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 />Print name <br />Signature <br />Address <br />City St Zip <br />Telephone ( <br />"Wf 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 />Date <br />13,03LIC 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 />S 40 <br />Owvev: Mt.0S rel./at/IA. <br />s510- -('f17? • <br />/5¢,/ : katy Otioe/ <br />2 4 1- ,113- 7J-97 <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