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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.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: ! 0 2 g D/�„1,,G��( I /✓ <br /> (� )- ! irf•�� <br /> ACTIVITY NUMBER: .r•cr)-* 7 - coo?,7 - v / f <br /> WAS PUMPED BY: /77 *.ry)I e rvek. ...e<ref•-C< <br /> DEQ License# 7$ -7 <br /> DATE TANK PUMPED: 7,+ / Z <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [ ] REMOVED <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 /> ,i CRUSHED ROCK <br /> COMPANY NAME: ?G)4 ( 5-c. {,C41011. <br /> SIGNED: 1i6 "- DATE: 3/612 ( <br /> MC S-02 <br /> rev:6/03, I2/I0 <br />