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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> _ - <br /> - Salem OR 97309-5036 <br /> (5.03)588-5147 FAX(503)588-7948 <br /> http://.publicvvorks.comarion.onus/liuildingt <br /> •- • <br /> • . <br /> SEPTIC TANK ABANDONMENT FORM. <br /> THE SEPTIC TANK AT: t 17 ride,c7cp,i ( <br /> 6 Liolicti <br /> • <br /> ACTIVITY NUMBER: * —00 <br /> • • WAS PUMPED BY: 4C • <br /> -• DEQ License# 3 <br /> . . DATE TANK PUMPED: '7 44*—43 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT livrni THIS FORM. <br /> THE TANK WAS: • <br /> • • • <br /> , I REMOVED <br /> . .„ <br /> • <br /> FILLED • <br /> (NOTE:The bottom of the tank should be perforated or cracked to prohibit the <br /> y • <br /> _ • accumulation of surface water in the tank) <br /> PILL MATERIAL: <br /> • . <br /> [3 REJECT sAND <br /> [3 BAR RUN GRAVEL <br /> CRUSHED ROCK' <br /> COMPANY NAME: <br /> SlGNED <br /> ,j/n' <br /> DATE: <br /> me 5.02. <br /> • rv.6/03 <br /> e <br /> sa <br />