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ECF..11VE <br /> MARION COUNTY PUBLIC WO.' <br /> BUILDING INSPECTION DIVISION AY <br /> 5155 Silverton Rd NE MARION COUNTS' <br /> • M 102021 <br /> 11111 • Salem OR 97305 <br /> (503)588-5147 FAX(503)$88-7948BUILDING NSPECTION <br /> I <br /> http://publicworks.comarion.or.usibuildingi <br /> SEPTIC TANK ABANDONMENT FORM <br /> TEE SEPTIC TANK AT: z 8 :potowooei Lo „se; Lyong, 012 <br /> 4173E8 <br /> ACTIVITY NUMBER: 7 / 70 <br /> WAS PUMPED BY: Pa r rvi e rs S .js+i.c. Co • <br /> DEQUcense# 3 4- /5 '7 <br /> DATE TANK PUIv1PED: 1 .) <br /> ENCLOSE A COPY OF TUE PUMPING RECEIPT WITH THIS FORM, <br /> TEE TANK wAs: <br /> r REMOVED <br /> pr 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 /> [ REJECT SAND <br /> BAR RUN GRAVEL <br /> bar CRUSHED ROCK <br /> COMPANY NAME: (0--)1 To 02-e Exceivcrli 2Lic <br /> SIGNEDc:ig-eL DATE: V7/"Zi <br /> .MCS-02 <br /> rev:6/03.12/10 <br />