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,' ►. a MARION COUNTY PUBLIC WORKS <br /> _ BUILDING INSPECTION DIVISION <br /> ''' ���" 5155 Silverton Rd NE <br /> am_ ... _:, ,., , <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publicworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: / 3 72 2 - /f eeA f-h6z/C 4 h <br /> Arc:. 1 A (0(2 1 G? -- <br /> ACTIVITY NUMBER: 5 Fj 5. — c)M" E)D $�__ -- <br /> WAS PUMPED BY: G #i7' (pt,J//S, <br /> DEQ License# - Z 3/ <br /> DATE TANK PUMPED: g--?-2-9' <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> NI 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 /> NiN BAR RUN GRAVEL �' <br /> [ ] CRUSHED ROCK0 ' <br /> COMPANY NAME: ii {/ S7-f M 1 \ <br /> 7 <br /> SIGNED: 13164/1°.7e- ° il---( ,Z9 <br /> DATE: 5--- 2 <br /> MC S-02 <br /> rev:6/03. 12/10 <br />