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i 114280-2020 San Joaquin County JOB: APPROVED BY: Celifomia Department Of Public Health OFFICE USE ONLY Compliance Form And-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use one form for each Pump or multiple bumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form Is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 116064.2. Under Section 116064.2(a)of the Health and Salary Code,effective January 1, 2010,the owner of a public swimming pool shall file this form within 30 days following the completion of construction or Installation of anti-entrepment devices or systema In swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. SfteInformation Chesapeake Landing HOA Spa Booser Facility Name: Pool Identification(if more than 1 poollspa at site): Facility Address: O RED SKY WAY City: RIPON st:_QA_zip: 95366 Owner Name: Owners Phone Number: 209507-7850 Owners Address City St.—Zip Pool constructed on or after January 1,20107. 0 Yes ■ No Pump Information Recirculation PumpI�y�Iet/BoostsrPump Challenger 2 —Make/Model_ _ H.P. Raka/Model g H.P �Other Pump: ❑Feature Pump 8ke/Model H.P- Make/Model—_-. _H.P Main Drain(Includes All Suction OutIP&Excant Skimmar Enualzer Lineal Al ORCFR101 Manufacturer of approved drain cover. Aqua Starl0"Rd-sumpless Model rvumcer: Install date 4-29-2020 GPM rating:Floor Wall Installed onDloor ❑Wap Manufacturer of approved drain cover: _ Rr�_Model Number. Install date GPM rating:Floor Wall installed onaloor❑wau Main drain/Jet suction pipe size is 2 inches. Check One: ©Split main drain(s)(Minimum 3 R.between covers,hydraulically balanced and symmetrically plumbed) ❑ Single drain–Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) Single drain–Not unblorkable (one of the following secondary devices required: safety vacuum release system,suction limiting vein system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: -- . .... ... __.._... Model/Part Number. Safety vacuum release system bears the following performance standard markings:0 ATSM F2387 0 ASMEANSI standard A 112.19.17 Skimmer Eauellzer Line(s) Manufacturer of approved suction fitting: Model Number. install date GPM rating:GPM rating:Floor Wall installed on Dioor ❑Well Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER 1 declare that I hold an active California State Contractor license# 608182 with classification C53 or a California State Professional Engineer license# with qualified experience working on public swimming pools and that the information provided above Is true to the best of my knowledge. 1 understand that if I improperly certify this Information,I shall be subject to potential j disciplinary action at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 116W.2. r Contractor/Engineer Name: Robert R.Burkett Company Name: Burkett's Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Zip Code: 95368 Contractor/Engineer Phone Number. 209 599-3317 Cell Phone Number. Contractor/Engmeer FAX Number. 209 5993317 Email: Robert R.Burkett 0-&A;t T UAIE& 5-16-2020 Contractor/Engineer name(PRINT) Contractor/Engineer name(SIGNATURE] Date For a complete text of the law,visit: http:lCMo son.ea.gov/pub/09.10/blll/asmlab 1001-1050fat_1020_blll 20091011 chaptered.pdf aeNse7:Juts 11,1070 Flu"K4