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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: Q G s S Now rr.,,le L c z <br /> Lycva S o, 4/7 gc,E <br /> ACTIVITY NUMBER: RS-- <br /> WAS PUMPED BY: CJ r c„< < 0-1.2rL., Z.L.-C <br /> DEQ License# SS44c <br /> DATE TANK PUMPED: 5- <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: c LL <br /> SIGNED: DATE: 4 -9-2Y <br /> MC S-02 <br /> rev:6/03,12/10 <br />