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RION COUNTY PUBLIC WORKS <br /> '`�`'-i ".: <br /> M'Q' BUILDING INSPECTION DIVISION <br /> == 5LS5 Sirlverton Rd NE <br /> - : Salem OR 97305 <br /> (503)588-5147 'FAX(503)588-7948 • <br /> • <br /> -hip://pahlicwarks.coanarion.or.us/bmfding/ <br /> ' SEPTIC TANK ABANDON FORK . <br /> T <br /> • • T�SEPTIC TANK AT: , . :/(O93V ,z7�� �4 .' <br /> • . ' : AC'I'�,VIZYNUMBER . <br /> • <br /> .:WAS PTJMPED B . • . 'EC D Se ("-i C. ' • <br /> _ - .DEQ T.icAr,eP#• . <br /> DATE TANK PUMPED: ' 6//lQ _ ?S • <br /> • 18NCLOSE A COPY OF THE PUMPING REClari.''Willi THIS FORM. • <br /> TBE TANK WAS: • .. • _ <br /> • <br /> . 6. • .REMOVED _ ` <br /> • FILLED • - <br /> (NOTE:The bottom of the lank should be•lie>foratd or rzacked to'prohibit <br /> • •- • al:cum,lat►on of sw.ce Water in the tank) _ ' <br /> • FILL MATERIAL: ' •• - • •• - •• • <br /> • • -{1 • i SAND ' ' • <br /> - E l- UN AR R GRAVEL ' <br /> . • CRUSHED RPCK - <br /> • COMPANY ) UCv\ C kK c I . . , • <br /> • <br /> : . SIGNED: 'DATE:. Vi, /O3 <br /> •. Mc8-02 • <br /> my - . <br />