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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 /> http://publieworks.co.mariomorms/building/ <br /> • <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: zo A.ALL <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY ra" <br /> DEQ License# <br /> DATE TANIC PUMPED: it 612_3 <br /> ENCLOSE A COPY OF 111E 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 /> [1 BAR RUN GRAVEL <br /> [1 CRUSHED ROCK <br /> COMPANY NAME: .F..(c <br /> DATE 8 (61r2--3 <br /> SIGNED: : <br /> ' mds-o2 <br /> rcv:603,12/10 <br /> '„ • <br />