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MAMON COUNTY PUBLIC'WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> Salem OR 91309-5036 <br /> (503)5884141 FAX(503)588-1948 <br /> . • <br /> http;//pUblicworks.co.marion.orius/Liuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT 4.S./1", j;t-rde.K <br /> AV ?NUMBER 09413 I <br /> . WAS PUMPED BY: •r)C c'..P(44-&`CL._ • . <br /> •i• DEQ Lidense# 3 30 /3 <br /> DATE TANK PUMPED: ' <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS.FORM. <br /> 4:t <br /> . THE TANK.WAS: <br /> • • • <br /> . [] REMOVED <br /> • • <br /> • . <br /> FILLED •i <br /> • (NOT : The bottom of the tank should,be perforated or cracked to prohibit the <br /> • <br /> • accumulation of surface waster in the tank) <br /> • <br /> • FILL MATERIAL: <br /> [] REJECT SAND <br /> [ BAR RUN GRAVEL <br /> CRUSTED•ROCK' <br /> COMPANY NAME: /•41e.1=-7; Se-12/-14e <br /> SIGNED:7LL,Z644.4.0...2.-_ DATE: r-c2 43 <br /> ,. • MC S-02 <br /> .• rcv•6.103 <br /> 4 <br />