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Marion County <br /> OREGON <br />COM/vIUNITY DEVELOPMENT <br />DEPARTMENT <br /> <br />SEPTIC TANK ABANDONMENT <br /> <br /> RECEIVED <br /> <br />MARION COUNTY <br />BUILDIN6 INSPECTION <br /> <br />THE SEPTIC TANK AT: <br /> <br />ACTIVITY NUMBER: <br />WAS PUMPED BY: <br /> <br />DATE TANK PUMPED: <br /> <br />(licensed D.E.Q. pumper) <br /> <br />THE TANK WAS: <br /> <br />REMOVED <br /> <br />FILLED <br />(note: the bottom of the tank should be perforated or cracked to <br />prohibit the accumulation of surface water in the tank) <br /> <br />FILL MAT.,,ERIAL: <br /> [.4' REJECT SAND <br /> [ ] BAR RUN GRAVEL <br /> [ ] CRUSHED ROCK <br /> [ ] OTHER:. <br /> <br />ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> <br />COMPANY NAMLe~ <br />SIGNED: ~/,._-.~ "'~_ d'~ DATE: <br /> ~ M~ion ~ Building ~eefion <br /> 3150 ~c~ter Dr. NE, Suite C <br /> Salem, Oregon 97305-1398 <br /> Phone: 588-5147 <br /> <br />abandon, mk 4/97 <br />MC-15-S2 <br /> <br /> <br />