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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://publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 5 L/ V b 4 yi d t e5OA Rd <br /> Aki,sv; <br /> ACTIVITY NUMBER: 5 5 5 — 2�'" Off/ N a-- PR m T-tl r <br /> WAS PUMPED BY: Fq(mtt' d cP f l[ <br /> DEQ License# •3 t/ 07 <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> M 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: G I d Vri ' <br /> i <br /> SIGNED: DATE: c g id/z 3. <br /> MC S-02• <br /> rev;6/03,12/10 <br />