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• <br /> • <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 /> httpJ/publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 668 Dqn ;ek tm <br /> ACTIVITY NUMBER: 5 5 5- 2 1 - 00 5 z6/-P N r <br /> WAS PUMPED BY: , l!rMeY5 Stpfic 'GYyi C t <br /> DEQ License# 3 0 l <br /> DATE TANK PUMPED: d 8 f 2 Z 11 <br /> • <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. &,d/7 rg;k) <br /> SIGNED: �' ` DATE: 6 1 Q l <br /> MC S-02 <br /> rev:6/03,12110 <br />