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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> hftp://publicworks.co.marion.orais/bnildingt <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: PY9K3 Plarki+ geo <br /> TT <br /> SA02.4%0311/ <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: SctIN-VeiltA Stf cembes <br /> DEQ License# <br /> DATE TANK PUMPED: t23 % <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 /> [I REJECT SAND <br /> H BAR RUN GRAVEL <br /> CRUSHED ROCK <br /> e .10 <br /> COMPANY NAME. Ce41‘ 4\ COI\ fir 146) _ <br /> SIGNED: DATE 2,3 <br /> MC S-02: <br /> rev:6./03,12,10 <br />