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._ MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> • <br /> - 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 FAX(503) 588-7948 <br /> http://publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: ! 1 (63 0() nek <br /> ACTIVITY NUMBER: Z/ -.6"// /6 //21• <br /> % <br /> WAS PUMPED BY: Occ_ E <br /> DEQ License# 3 J 61/3 <br /> DATE TANK PUMPED: 2/g)ypozn <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> XREMOVED <br /> [] 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 /> • <br /> FILL MATERIAL: <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY N //l Tik <br /> SIGNED: DATE: /d(e() ri di <br /> MC S-02 <br /> rev:6/03,12/10 <br />