Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 \l� <br /> (503) 588-5147 FAX (503) 588-7948,--� � l � <br /> `'�- - ,lJ <br /> http://publieworks.co.marion.or.usibuilding( <br /> (�t' a 20 <br /> gyp® <br /> � :.. MNSPt�� EC11°�� <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 3 cQ5 L'k-p_ <br /> Sa I-ern , eie- <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: 1 ,3 <br /> DEQ License# 3S 1 37 <br /> DATE TANK PUMPED: ?/ 1 I q �. <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> [I-K- <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 /> [t]- BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: Arvi eaI-PA/ 1/j' l <br /> SIGNED: / /� DATE: 3 1 (9 <br /> MC S-02 <br /> rev:6/03, 12/10 <br />