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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 /> han://uublicworks.co.marion,nr.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> TEE SEPTIC TANK AT: 5c7 Cl A/ICA b Ce'r t 1. e 7(/ • <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: I frl t <br /> DEQ License <br /> DATE TANK PUMPED: 72 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> TANK WAS: <br /> [I REMOVED <br /> 47- 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 /> [ ,-. EJECT SAND <br /> [111 BAR RUN GRAVEL <br /> • [] CRUSHED ROCK <br /> r <br /> r COMPANY NAME: / /17 <br /> SIGNED: 1)1'2-2;277 DATE: 7-/;- -2-5/ <br /> Cbtronnsteptia.S-02 Abandonment Fonmdoc <br /> revt 5/03, <br />