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_ .. . <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silvertou Rd N.E <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588.-79U <br /> http://publicworks.co.ritarion.or.asibuildingi <br /> SEPTIC TANK ABANDONMENT FORM <br /> _ ---, <br /> : .1 •:.---,*; <br /> ., . <br /> THE SEPTIC TANK AT: .. <br /> .. , <br /> ( )41r.e...> C>e...... 1-73-tk......___ <br /> . . <br /> . , <br /> .... ACTIVITY NUMBER: <br /> WAS PUMPED BY: Fr.() cc,e_Oti" s <br /> c. <br /> DEQ License'# 3c13 I <br /> DATE TANK PUMPED: 2 5/36 3- <br /> 1 <br /> ,,.. <br /> ' . . <br /> : - ENCLOSE A COPY OF THE PUINTPING'RECEFRT WITH THIS Foam. <br /> THE TANK WAS: <br /> j j ,REMOVED <br /> - i <br /> . . <br /> ' X FILLED <br /> . , <br /> . , <br /> ,-- . <br /> (NOTE:The bottom of the tank should be perforated or cracked to prohibit the ., <br /> .. . . <br /> accumulation of surface water in the tank) <br /> . . <br /> FILL MATERIAL: <br /> . . . . <br /> , .. • <br /> REJECT SAND <br /> • . .14, BAR RUN GRAVEL• <br /> . [j CRUSHED ROCK <br /> , _, .. <br /> COMPANY NAME: , „EC:1:z, <br /> .. - <br /> SIGNED: , DATE: <br /> MC..542 <br /> row 403,12/10 <br /> 10 r •r' \ .., <br /> 'i ' • <br /> ! , <br /> i . <br />