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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(543)588-7948 <br /> http://publicworks.co.marion.or.us/buildingl <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: ` 7 2 0Z r''". pc) <br /> Sct.:4 -- Ravi c P T71`5 ` <br /> ACTIVITY NUMBER: <br /> e� � <br /> WAS PUMPED BY: OY -V) •- CA*'C�V' 3 Dee(;►"� <br /> DEQ License# s ! t er <br /> DATE TANK PUMPED: EC- <br /> -- <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [4,-. 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 /> [] CRUSHED ROCK <br /> ✓ it4.i � � ;h Sa�� 1oC3b►i <br /> COMPANY NAME: F7o .r�nc.- Corts+rud-r <br /> SIGNED: ~ 6:7) DATE: <br /> MC S4 2 <br /> rw:64Y3,12110 <br />