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MARION COUNTY PUBLIC WORKS • <br /> • ' � ''' BUILDING INSPECTION DIVISION <br /> _ 5155 Silverton Rd NE <br /> • <br /> Salem OR 97305 <br /> (503) 588-5147 FAX(503) 588-7948 <br /> http://publicworks.co:marion.or.uslbuildin.g/ • <br /> SEPTIC TAN*ABANDONMENT FORM <br /> • <br /> THE SEPTIC TANK AT: LQsJ S Fr t A Pe <br /> 56.4A-A <br /> . ____.._ <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: - /4-CA, S <br /> • .DEQ License# J, <br /> DAl'E TANK PUMPED: ' ! i l ' d UV <br /> ENCLOSE A COPY OF TILE PUMPING RECEIPT WITH TUTS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> • <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 /> [] BAR RUN GRAVEL <br /> gCRUSHED ROCK • <br /> COMPANY NAME: •N 5e-pgi.• <br /> ,SIGNED: <br /> MC S-02 • <br /> rev:6/03 • <br />