COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

JOB: 114280-2020 San Joaquin County APPROVED BY: California 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 1160764.2 NOTE:Use one form for each Pump or multiple pumps 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 Safety Code,effective January 1, 2010,the owner of a public swimming pool shall file this farm within 30 days following the completion of construction or installation of anti-entrapment 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. Site Facility Name: Chesapeake Landing HOA Pool Identification(if more than 1 poollspa at site): Spa Facility Address. 1660 RED SKY WAY City; RIPON St:��Zp: 95366 Owner Name: Owner's Phone Number: 209507-7850 - Owners Address City St—Zip Pool constructed on or after January 1,201 DT: o Yes 2 No Pump Information Pentair Recirculation Pump IV M �e' /BoosterPumpake/ModelVS+SVRS H.P.3 eke/ModenOther Pump: eature Pump ' ake/Model. _H.P_ Make/Model _ _H.P Main Drain(includes All Suction Oudats E�Pnt Skimmar Enualtzer Une?l Al ORCFR101 4-29-2020 Manufacturer of approved drain cover. Aqua Starl0"Rd-sumpie ss Model ivumoer: Install date GPM rating:Floor Wall Installed onEjloor ❑Wall Manufacturer of approved drain cover: _ LL_Model Number. Install date GPM rating:Fioor Wall Installed or[IFIDor Q Wall Main drainlJet suction pipe size is 2 inches. Check One: ®Split main drains)(Minimum 3 ft.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 unblockable (one of the following secondary devices required: safety vacuum release system,suction limiting vent 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: -- _ ... ._..__... Mcdel/PartNumber. Safety vacuum release system bears the following performance standard markings:o ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer Eaualtzer Linefs) ABANDON Manufacturer of approved suction fitting: Model Number: install date GPM rating:GPM rating: Floor Wall Installed on D7oor []Wall AUTO FILL DEVICE Skimmer equalizer line(s)pipe size were found to be NSA inches Number of Skimmers: 2 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I 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. I understand that if I Improperly certify this Information,I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. 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: 209 599-3317 Email: Robert R.Burkett At,d_ Z ( 5-16-2020 Contractor/Engineer name(PHI Contractor/Engineer name(SIGNATURE) Date For a complete text ofthe law,visit http:f/infoson.ca.govipub/03.101billtasmiab 1001-1050tab 1020_bill 20091011_chaptered.pdf a.Ys .MY 14,2010 �p n521�n