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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.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: log ?�, Ju`s L'vw � �'� s e <br /> 9'7 .35.2 <br /> ACTIVITY NUMBER: -�-' l 62 e 0? 3 1• <br /> WAS PUMPED BY: ( ��d- 4, L' J L L C..a <br /> DEQ License# 3 9/ <br /> DATE TANK PUMPED: ( 3 1 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> TNR TANK WAS: <br /> [ ] REMOVED <br /> .A 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 GRAVE., <br /> CRUSHED ROCK <br /> COMPANY- 'A: <br /> SIGNED: � <br /> DATE: r <br /> • <br /> MC S•02 <br /> rev:6/03 <br />