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itt ECENED <br /> MARION COUNTY PUBLIC WO ' <br /> BUILDING INSPECTION DIVISION <br /> MAY <br /> ..... .-.„-reOvertoRd NE MARION COUNTY <br /> Mis ,-N <br /> 1 0 2021 <br /> . 5155 n <br /> Salem 97305 <br /> (503)588-5147 <br /> OR <br /> FAx(503)5884948BUILDING INSPECTION; <br /> http://publicworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> . THE SEPTIC TANK AT: // 0Z8 .7) 0,3w0041 Lil Se, Lyon g, OR <br /> /73E8 <br /> ACTIVITY NUMBER: 7 / 70 <br /> WAS PUMPED BY; arYney-s Serf'I c Co . <br /> DEQ License# 3 4- 6 '7 1 <br /> DATE TANK PUMPED: 1 ! •-• ) 0 —Z 0 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> Pir FILLED <br /> (NOTE: The bottom of the tank should be perforated or cracked to prohibit the <br /> accumulation of surface water in the tank) <br /> FILL MATERIAL: <br /> [I REJECT SAND <br /> [1 BAR RUN GRAVEL <br /> bir CRUSHED ROCK <br /> COMPANY NAME: km To c.o.e E-xce4vcdi on 211 C <br /> SIGNED: -11-y- .4)- '',..)-2er--- ---- <br /> c/V-0 DATE: 7 <br /> / <br /> MC S-02 <br /> rev:6/03,12/10 <br />