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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155:S01,0.ton Rd NE <br /> 1111111 Salem OR97305 <br /> (503)-588-5147 FAX(503)588-7948 <br /> httP://publieworks.co.marion.onnsfbuildingi <br /> SEPITCTANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: P)MS-6 tilark goo <br /> Tie <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: S ... <br /> . etil., ,ipp. tp4., Sembes <br /> DEQ,License* <br /> DATE TANK PUMPED: qta-S ZS , <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS:. - <br /> I 1 REMOVED <br /> .,0 FILLED .1 <br /> (NOTE:The bottom of the tankshotild be perfomted or cracked>to prohibit the <br /> accumulation of surface water in the tank) ,, <br /> , <br /> FILLMATERIAL: <br /> [J REJE,CT SAND <br /> [I BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: 1.46) Ci\efAibp, COA +ICC c's*-- 1 , <br /> SIGNED ,..,65: 7, <br /> : _ -, °"111111ftlea. DATE: <br /> .!•!-- <br /> MC S.02, <br /> mi.;003,Una <br />