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,4,,. MARION COUNTY PUBLIC"WORKS
<br /> - ':,,.. ,.. BUILDING INSPECTION DIVISION,,.
<br /> = �' � 5155 Stivertvnu Rd NE Saleua 0R97345
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<br /> 3o}r 5'u8s8/b7u9i4l d8i n;:SEPTIC TANK ABANDONMENT FORIYI
<br /> •
<br /> THE SEPTIC TAK AT L( 9 1 :AI � ' c4 vi J4i ..
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<br /> it{ -' .'
<br /> ACTIVITY NUMBER . cS - Y ,
<br /> WAS PUMPED BY Sc,+ 'I I. _ .; r
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<br /> DEQ-L,icense;# )
<br /> DAi E TANK PUMPED n
<br /> EN .,,,„,-.7,_,2--,-..,',,. , '...•..' : ':.:•:-.---',;:.,•:::.,•-,,. ::::::...,,::_:,,::::1-.-.:,.,::•:::,,,,.;:-...:=.:::::,,,,, .„• :'..,•:::.,L.,:'1,,,...,-....••=:,,..,:,:,,,:,...„'•,..:.,,,,,:;;,,,,,::,:::::,,...,•:.,1,..,..::.;,-„,:::,,,:',',,,,.:T.,,'...,:i....T:,".-;.,•,,!,,::::,:-;,,,...!
<br /> CLOSE . - r
<br /> A COPY OFT 3• PIJ;- .. :�G.:RECE I'T WITHT>FIIS FORM:
<br /> THE TANK WAS..
<br /> . ' . • REMQUED •3
<br /> ;j] FILLED
<br /> (NOTE, The b ottom of the•tarik• = � '- should.be perforated or cracked to prohibit the;
<br /> accumulation ofsurface water, n the tank}.
<br /> FILL.MAI'LRIAI,
<br /> �]
<br /> REJECT SAND : ,
<br /> B'AR RUN GRAVEL
<br /> {]. : CRUSHED"ROCK .
<br /> •_ •...-...: ,..• . •,. ..• •
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<br /> COMPANYi`t. " rs �c
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<br /> SIGNED °, ` DATE: 7 -,: .o
<br /> MCs02'
<br /> my 6103.I21t0
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