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MARION COUNTY PUBLIC WORKS. <br /> ki BUILDING INSPECTION DIVISION <br /> —7= 5155 Siiverton Rd IYE <br /> Salem,,OR.97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publieworks.cosnarion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 3. 18t77/4/FoRic <br /> ACTIVITY NUMBER:. . <br /> WAS PUMPED BY: 7//( Rgo.oE27 <br /> DEQ License# F .4 t4P7 2 7i/E r/RE <br /> DATE TANK PUMPED: <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: <br /> SIGNED: l4i&..ri(2DATE: g=-2 7T 2L/ <br /> G:WormslSeptiolS-02 Abandonment Form.doc <br /> rev:6/03,12/30 <br />