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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silvertoo 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: 9j a-] 91,1 I u,y Ave <br /> S Aver Ira vt /'TRH /7S�y \ <br /> ACTIVITY NUMBER: DYLQ _ VitiazuiaWAS PUMPED PUMPED BY: (peg Seel* C ""ll <br /> DEQ License# 390-7) <br /> DATE TANK PUMPED: IO- //-2AO,35 <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: PCP t E.rw044<A4 Inc <br /> SIGNED: DATE: - 20ZJ <br /> MC S-02 <br /> rev:6/03,12/10 <br />