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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> rj�= 5155 SlIverton Rd NE <br /> mi. <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publicworks.co.marion.or.ns/bullding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> q 1 <br /> THE SEPTIC TANK AT: I + ? A Y� (f V� ( I /\ s-E <br /> diQ <br /> 0611 38 <br /> ACTIVITY NUMBER:WAS PUMPED BY: C Q 1 5 S t'e i i L <br /> DEQ License# 311 Lilf <br /> DATE TANK PUMPED: 1 1 o 1 ('i <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 /> [V BAR RUN GRAVEL <br /> CRUSHED ROCK <br /> COMPANY NAME- C /'d Dr <br /> SIGNED: j DATE: a 7 id/ <br /> MC S-02 <br /> rev:6/03,12/10 <br />