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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: 2.2 go n�c:. /d <br /> L7D"5 o,Z f 7.3 S <br /> ACTIVITY NUMBER: / <br /> WAS PUMPED BY: Qveja� f : b/c_ I o.'/e L LL c <br /> DEQ License # <br /> DATE TANK PUMPED: (o / ,2 2/20.22 <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 NAM : <br /> SIGNED: `�!�— DATE: 06l30l2vay <br /> MC S-02 <br /> rev:6/03,12/10 • <br />