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MARIO►N COUNTY PUBLIC WORKS <br /> - a�_i ry ___ :�'���o_-� - BUIIIDING INSPECTION DIV <br /> ISION <br /> - <br /> y �• ;� 5155 Siperton RdE <br /> = _ = _ Salem OR 97305 • <br /> ~ <br /> _. =_`-`';-==- (503)588-5147 •FAX(503)588-7948� ~_: http://pnblicworks.co.marion.or.us/btuld ne <br /> • • SEPTIC TANK ABANDONMENT FORM . <br /> THE SEPTIC TANK.AT: • . 1.-3-SC . 5-5-' • Ave. /vb . • • - . . • - - <br /> . . . : ACTIVITY NUMBER.: ' <br /> PUMPED BY: . 0 J`e�.c� v�� k CL . k _ <br /> WAS U S . <br /> .DEQ License • 3 gc1c o _ - <br /> DATE TANK PUMPED: . — 2_5 - 7.42 2 <br /> • <br /> y . <br /> • •ENCLOSE A COPY OF'1 THE PUMPING REC`EIYT'W!' a THIS FORM. • • <br /> ',LEE TAl WAS: • - <br /> • .[ - REMOVED . . - <br /> (NOTE:The bottom p <br /> of the tank should be erforated or cracked to•prop bit the <br /> •- • accumulation of surface water in the tank) - ' <br /> • FILL MATERIAL: - - : ' - • - • . • <br /> [] RE7ECT.SAND • . <br /> • . - []• .BAR RUN GRAVEL - <br /> • [] : CRUSHED ROCK - <br /> • COMPANYNAM : cJ 6t.e* : AN,vtej lq c_..\411,A.A.t...0„v;Nw►--. . • ' - <br /> SIGNED: � , /� �I <br /> !'� t%� : DATE:_ Z-?'l <br /> MC 9-02 - <br /> • rcv:6/03 . • <br /> • - . <br />