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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 1111111 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: -C C� /714i- 4//'/Ic R V <br /> n( q")]/7 <br /> ACTIVITY NUMBER: .C-- S- VI - a 37a -P( f r <br /> WAS PUMPED BY: „'( f , c <br /> DEQ License# 196) <br /> DATE TANK PUMPED: 7115/211 <br /> ENCLOSE A COPY OF'1'Hr;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 /> • <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> p9, CRUSHED ROCK <br /> COMPANY NAME: 1�el 1�e{ F:74(SIGNED: •=j9-. .. 64A v( DATE: 7l l 7/ Z el <br /> MC S-02 <br /> rev:6/03,12/10 <br />