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• <br /> 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 /> httn://nublieworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 11297 Pioneer Rd SE Lyons, OR 97358 <br /> • <br /> ACTIVITY NUMBER: 55 5 4a LI- OQ G SP( <br /> WAS PUMPED BY: 4 See. no to <br /> DEQ License# <br /> DATE TANK PUMPED: See Aote <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> • <br /> THE TANK WAS: <br /> [x] REMOVED The entire system (tank&crushed drainfield)was removed by Fema shortly <br /> after the Santiam Canyon fire. <br /> [I 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: Fema related company <br /> SIGNED: Richarda Tapken DATE: 9/5/2024 <br /> ***Please let me know if I need an original vs digitized signature and I will scan back. <br /> G Womms\Septic\S-02 Abandonment Form.doc <br /> rev:6/03,12/10 <br />