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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 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: f t j1)m 1,'Jy <br /> GcleS <br /> ACTIVITY NUMBER: Sir --02 '1 - 06,363.0 P/?4 j 7 <br /> WAS PUMPED BY: Scxv} 4-141. Pool/irtg <br /> DEQ License# 3 ct_i 9 <br /> DATE TANK PUMPED: �-l t-J a `1 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> [?l, FILLED c,Nvs <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 r, <br /> pi BAR RUN GRAVEL <br /> [] CRUSHED ROCK 1\'Y <br /> COMPANY NAME: ejezt/4 $'fed � <br /> SIGNED: 1U DATE: S-a f�a y <br /> MC S-02 <br /> rev:6/03,12/10 <br />