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r <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 1111111 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: if / 2-7 4uiborin (;d NE <br /> astrY), <br /> ACTIVITY NUMBER: C i� dt e ci l m 2 3 - I Z 0 11d "oo- p <br /> WAS PUMPED BY: C 4 rl S G }j c Strvi[C <br /> DEQ License# 3 I r y`l <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> NOTE: CopiwgC Tf D -ro Cf Y 5411ER <br /> THE TANK WAS: <br /> [] REMOVED <br /> 1/ 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 /> [iY CRUSHED ROCK <br /> COMPANY NAME• '4 >d/J 1DrQ;h <br /> SIGNED: ` DATE: / Z// yi 3 <br /> MC S-02 <br /> rev:6103,12/10 <br />