Laserfiche WebLink
�., MARION COUNTY PUBLIC WORKS <br /> BUILDING'INSPECTION DIVISION <br /> 5155 Silverton Rd NE IlE <br /> 1111111 <br /> Salem OR 97305 1VJ <br /> (503)588-5147 FAX(503)588-7948 http://pubiicworks.co.mario:n.or.us/building! AUG 0 9 2021 <br /> MARION COUNTY <br /> SEPTIC TANK ABANDONMENT FORM lJBI DICUC INsPECTION <br /> THE SEPTIC TANK AT: ' 0?7-. ,94€ <br /> ACTIVITY NUMBER: c 5-21 r2o33 Lig-pg.,47T <br /> WAS PUMPED BY: Sew? 1c o S . <br /> DEQ License# 1ZZ <br /> DATE TANK PUMPED: p iz/5,6.tfi..-d <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> REMOVED <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 /> FILL MATERIAL: <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: &pan Sir rn ccs LG. <br /> SIGNED: :� �% DATE: 47W/�� a»( <br /> MC S-02 <br /> rev:6/03,12110. <br />