Laserfiche WebLink
APPROVED BY: <br />DATE: <br />orricr USE ONLY <br />OCT-04-2014 17.44 From:Burkotts 2095453848 <br />Joaquin County <br />California Department of Public Health <br />Compliance Form <br />Arel-Entrapment Devices and Systems <br />for Public Pools and Spas <br />Health and Safety Code Sections 116064.1 and 116064,2 <br />NOTE: Use one form for teeter:mime or multiple pump; under thessemdrein cover. <br />ALL SECTIONS OF THIS FORM MUST BE COMPLETED. <br />This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Cede sections 116064.1 and <br />116064.2. Under Section 116064_2 (a) °tithe Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool <br />shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems In <br />swimming pools. Contact your local Eniironmental Health Department and Building Department for any necessary plan approval and <br />permits prior to construction or remode1.11 <br />She ittoyratIon Pool <br />Facility Name: Waterstone Apt Poe! Identification (if more than 1 pool/spa at site): <br />Facility Address: 1951 West Middlefield Dr. <br />Owner Name: 81' 209Ca 83( li P:159850377 s Phone Number. <br />City: Tracy <br />Owners Address t City St. Zip <br />Pool constructed on or after January 1, 20107: a Yes 1 No <br /> <br />,ojnformsUon 1 <br />Recirculation Pump Qiet / Booster Pump <br /> ake/Model _ StaRite H.P.1.5 1_, ake/Model _ <br />ImOther Pump: Lj Feature Pump <br />ake/Model , el P Make/Mod& <br /> <br />H.P <br /> <br />_H.F <br /> <br />MalDSIITIn fincludee_All Suction Outlets ixctent Skimmer enuatizer Lino). P12101 <br />Aqua Star 12" square Vie nufacturer of approved drain cover. Model Numper: , Install date 9-30-14 <br />3PM rating: Floor 360 Wall Inetallaci ont .loor CI wall <br />Vlanufacturer of approved drain corer: Model Number Install date <br />3PM rating: Floor Wall Installed on Floor ID Wall Main drain/Jet suction pipe size Is 2 inches. <br />check One: <br />WI Split main drain(s) (Minimum 3 ft. between covers, hydrautically balanced and symmetrically plumbed) <br />I=1 Single drain — lJnblockable (size aid shape that a human body cannot sufficiently block to create a suction entrapment) <br />0 Single drain — Not unblockable (one of the following secondary devices required; safety vacuum release system, suction limiting vent <br />system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) <br />Type of secondary device installed: Install date <br />Manufacturer of approved device: 1- ... Model/Part Number <br />Safety vacuum release system bears the following performance standard markings: ID ATSM F2387 o ASMEJANSI standard A 112.19_17 <br />Shimmer El:waltzer Linefe) <br />ved SUCtiOti fitting: Aqua Star 10" round/ sui Model Number Install date <br /> <br />Al ORCFR101 9-30-14 manufacturer of appro <br />GPM rating: GPM rating; Floor 170 Wail 164 installed on 1 hoor .,/ Wall <br />Skimmer equalizer line(s) pipe size were foUnd to be 2 . inches Number of Skimmers: 2 <br />THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATIP.NREQUIRENIENTS ElY THE INSTALLER <br />I declare that I hold an active California State Contractor license # 808182 with classification C53 or a California state <br />1 Professional Engineer license # with qualified experience working on public swimming pools and that the information <br />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 <br />disciplinary action at the discretion of the liCensing authority in accordance with California Health & Safety Code Section 116064.2. <br />Contractor/Engineer Name: Robert R. Burkett Company Name; Burkett's Pool Plastering, Inc. <br />Company Address: P.O. Box 938 <br />City: Salida I State: Ca zip Code: 95368 <br />Contractor/Engineer Phone Number: 209 699-3317 <br />Contractor/Engineer FAX Number: 209 599-3317 <br />Robert R. Burkett <br /> <br /> , Q ----"---6 10-4-14 1 <br />ContractOr / Engineer name (PRINT) Contractor / (Engineer name (SIGNATURE) Date <br />For a complete text of the law, visit: httpAnfo-sen.ca.gov/pub109-10lbtlifirainIab_1001-1050fab_1020_bIll_20091011_chaptered.ptif <br />To:12094540138 Pogo:3/3 <br />JOB: <br />77727-2014 <br />Cell Phone Number. <br />Email: <br />Received Time Oct. 4. 2014 5:41P P<CMC$'1, Jutl 14. 2C10 V No. 7245