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A Division of San Joaquin County Health Care Services <br />PUBLIC litEALTH SERACES <br />SAN JOAQUIN COUNTY <br />, EN"Mk07•11M4117.4. ItakITH DIVISION <br />ukaren 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-7.,07,44. <br />(.) 2461 6/ r 4/4"6/ <br />------..) NCA IA ! fY <br />.?' • ..=,,Elfr''a. ..0, <br />.c:ti rif i: i p co' <br />Site address of pool(s) g/ ,doeiAAJ <br />City <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />/ ,fre-e)-6 <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 />Date <br />City St Zip <br />Telephone <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 />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 />17/6-- 40606 <br />6 c 4,) <br />4)45- -7-ES7O /-4/ Oo <br />0,C),/ <br />/ 6D SW9 66 6-.E.C7-c4ja_,4(__ <br />E0) 053 3