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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: /3 166. 12 c c S ,GZc <br /> S<<� ((:wL 'i73S1 <br /> ACTIVITY NUMBER: fir-SS' -o2LL C 3 <br /> WAS PUMPED BY: <br /> DEQ License# dolt ra.&-3 <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> pcip 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 /> tip REJECT SAND r1ta-- <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: SI.wW <br /> SIGNED: DATE: q^,1-21 <br /> MCS-02 <br /> rev:6/03,12/10 <br />