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-- <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 /> http://publieworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: A/04Lp Lihy E <br /> \TifPc r5 Dr) ibR, q7.2 1/45c <br /> ACTIVITY NUMBER: _______________WAS PUMPED BY: For*mffiz epti r. (D <br /> DEQ License# 3 bj 07 <br /> DATE TANK.PUMPED: q /a <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 sin-face water in the tank) <br /> FILL MATERIAL: <br /> 44-- REJECT SAND <br /> [] BAR RUN GRAVEL <br /> fl CRUSHED ROCK <br /> COMPANY NAM : DATher <br /> SIGNED: e.„ " DATE: q <br /> MC S-02 <br /> rev:6/03,12/10 <br />