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�. MARION COUNTY PUBLIC WORKS <br /> "'` BUILDING INSPECTION DIVISION <br /> mai- - - ....-" 5155 Silverton Rd NE <br /> 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: -5Sc-- c i2- $ <br /> 5c.47-1,14, Of.- <br /> ACTIVITY NUMBER: C 5- Z ?—6041 [C-I S <br /> WAS PUMPED BY: — C�t 't - kat- c�c-s pc: tr_,a.� <br /> prey- iv `24/rc-i-.kse tareeivvewt- <br /> DEQ License# _at vkts ,,uL c✓45 .eu„p v <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> p 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 /> kl BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: Gvt C.-wriv-- -if- 914.0.� I 1 <br /> ___----- <br /> SIGNED: DATE: 7-/Z--v2 <br /> MC S-02 <br /> rev:6/03,12/10 <br />