|
.. .
<br /> . ,.. .
<br /> - . • .
<br /> , ' - - • •
<br /> • .
<br /> • .MARION COUNTY PUBLIC WORKS
<br /> BUILDING INSPECTION DIVISION
<br /> 555 Court St NE/PO Box 14500
<br /> -..., . ,.. , •_-_-----.----:,.:‘,--•--N . • .
<br /> .,.. .
<br /> Salem OR 97309-5036
<br /> - •
<br /> • (503)588-5147 FAX(503)588-7948
<br /> 1 :••••. .
<br /> httilt//publicworks.co.marion.or.us/building/
<br /> .:,•n:• .. •: -
<br /> . ) •
<br /> • • -
<br /> . .. ..--... ,. •,..
<br /> . SEPTIC TANK ABANDONMENT FORM . . .
<br /> . . . . .
<br /> •
<br /> , . -,. •
<br /> . -
<br /> THE SEPTI6 TANK.AT: ' . - '.-cPcg ,-f22.,.... -)P1 t A)ti-. .. . (c,,t- ____. . •- . '
<br /> 1 , • .
<br /> .2
<br /> • . ; s - . . . (y06'.1 ) • 0 tic--
<br /> .. . . . .
<br /> , , . .. . . . . • . ,..r.,.-• -.-,•31.-.4,4p,,,
<br /> ACTIVITY NUMBER: • •5-75.S.-.A9.-&'''',.3**,41q,•-t-:.A..
<br /> . .. ••
<br /> :!..,; . *. .. . •,. •WAS PUMPED BY: . eS e r . it'p-I-:/"C-- . • .
<br /> . .
<br /> •
<br /> •
<br /> ::•::: . : . '7:...:. ..:. • - DEQ License# 3?c,i
<br /> •-,...',. - .: .. L."-
<br /> , .
<br /> DATE TANK
<br /> . . • . .
<br /> . , . .... • . . .
<br /> • • • '' ' - . .
<br /> . ' . . • . I ENCLOSE A COPY OF THE PUMPING,RECEIPT WITH THIS FORM. • • -
<br /> . . .
<br /> • .
<br /> ..,
<br /> :"2:" . ' •.-''' • ' THE TANK WAS: . . . •
<br /> 4:: .-- .•• ,:.:. ... . •
<br /> , . . . •
<br /> • • -• .. .
<br /> .-• • ,
<br /> i •• . :-.. ,..
<br /> . _ ...
<br /> •• ,
<br /> . ,
<br /> • [] FILLED . - -.. • • „:„.,..,• . , .
<br /> . .
<br /> •
<br /> • . . •
<br /> • (NOTE: The bottom,ofthe tank should be perforated or cracked to prohibit the , - •
<br /> " accumulation of surface water in the tank)
<br /> •
<br /> •
<br /> I I •
<br /> FILL MATERIAL:. • • .
<br /> :?•;",.:. .,..•,•!., . •
<br /> • .
<br /> :,:1,. -: .::. • ..-:- .• • [J REJECT SAND .•. . •
<br /> •„,...:;•• '• : '. • . [] BAR RUN GRAVEL • . .
<br /> "if' - :. ,, . . --• • . [3 CRUSHED ROCK
<br /> . - .
<br /> re-, / cii.
<br /> COMPANY NAME: IC)C E... e, t-C.. • • : - ,
<br /> ..:•?.,.,.-,.-, . . . .. . , ,. • z, A,
<br /> .:-. .. - • SIGNED: .--79. ....,. ...-K . _ • 41V.pe(..e,C____ DATE: c#-• (.(/‘-'73C2:P•(
<br /> • . .
<br /> , •
<br /> •
<br /> • . .
<br /> 1 . •• . :revt.6103
<br /> - .' , '• -. ., .
<br />
|