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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: 871 Iva Ln <br /> Salem, OR 97313 <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: Bennett Septic Service LLC <br /> DEQ License# E and Z Excavating LLC DEQ#39104/Bennett septic service DEQ#39252 <br /> DATE TANK PUMPED: 8-6-2024 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> pg 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 /> D4 REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: E and Z Excavating LLC <br /> SIGNED: Cum' `5ii' DATE: 8-8-2024 <br /> MC S-02 <br /> rev:6/03,12/10 <br />