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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: 11 S H p �� S•1. <br /> � �. ►ts , o � 9739' <br /> ACTIVITY NUMBER: ,j 3 5 2 r ®o 471257 „ 1fri r <br /> WAS PUMPED BY: FCC) Se 1 <br /> �� z Service <br /> DEQ License# 3 526 1 <br /> DATE TANK PUMPED: p r Z(o <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> REMOVED <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 /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: Kr ►1 / be 2 c_ EX c 0 c,J , y� <br /> SIGNED: /41L- C , - DATE: 8 - 2 C -2 y <br /> MC S-02 <br /> rev:6/03,12/10 <br />