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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.uslbuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: II O SE <br /> 1-4-Lir)R 9--)352 . <br /> ACTIVITY NUMBER: ASS — 21 -oil I ell(11 <br /> WAS PUMPED BY: :r►tr►) <br /> DEQ License# el CI U7/ <br /> DATE TANK PUMPED: 10 I/ 8(2 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> Ettl 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 /> [[k CRUSHED ROCK <br /> COMPANY NAME: V> 1 6E <br /> SIGNED: -Li_ 03 C:-14f P// DATE: .) ! /qb <br /> MC S-02 <br /> rev:6/03,12/10 <br />