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MARION COUNTY PUBLIC WORKS <br /> " »T 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: 560 N Santiam Hwy W <br /> Gates, OR 97346 <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: A&B Septic <br /> DEQ License# DEQ 38137 <br /> DATE TANK PUMPED: 4/4/2024 No home attached pumped at eval <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> Crushed and filled <br /> X 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 /> X CRUSHED ROCK <br /> COMPANY NAME: 3-A Construction, L C. CCB# 167959 DEQ 39002 <br /> SIGNED: DATE: 09/04/2024 <br /> MC S-02 <br /> rev:6/03,12/10 <br />