Laserfiche WebLink
'4t ARION COUNTY PUBLIC WORKS• <br /> l3f.f.J l l .CA 1NSPE ( i ION DIVISION� k 1 <br /> � C ya 5 <br /> `'1.;555ti��t.F4('ro Rd iNE Salem, OR 9-;305 <br /> tItti);llpublicwoolis.ea.marion.oratsibultditkoi <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK K AT: C\\7 )-\ C?cA 1`N <br /> ACTIVITY N L'.MBER: <br /> WAS PUM'lP.ED BY: '\ \cr cA401 e 5 LAL,•C <br /> DEQ License '" j C'( 4--1 C'1 <br /> . :DATE TANK PU? ED: (.6- C ' ` <br /> ENCLOSE A COPY OF TIE PUMPING RECEIPT WITH THIS FORM. <br /> T 1M TANK WAS. s) <br /> /1. REMOVED 111 y lilt) <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 /> [] REJEC:i SAND <br /> [3 BAR RUN GRAVEL, <br /> 1 CRUSHED ROCK <br /> COMPANY NAME: cs( <br /> #;iG'."3 D: %i!' __ __ .. l ATE: <br /> w g - t <br /> .T."[X7:S,%a¢,tT:Y P..6w^,:.LttC.ati <br /> �rl''iK , . .-..i ;aoat;='i^ c*��:u�yw:�aanww-s-a - ,, :: . , .-.. ....._ vmt�vrWmF't�It+P7 <br />