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r '4- <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://publicworks.co.marion.or.us/building/ <br /> C" Ask <br /> s <br /> llI <br /> EWE <br /> SEPTIC TANK ABANDONMENT FORM MAR 212019 <br /> 1.U'SLN I i INSPECTION <br /> ACTION <br /> THE SEPTIC TANK AT: ‘Wei d12a <br /> /i)23�1 <br /> ACTIVITY NUMBER: 695 -- 1 B—b d Lt18 <br /> WAS PUMPED BY: CA✓LQp.v� <_ ,t-+_,,�- V-1 �`� <br /> DEQ License# �Oget(0 <br /> DATE TANK PUMPED: -1 c <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> yD 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 /> [1 REJECT SAND <br /> BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: J10 ,• <br /> SIGNED: DATE: /—f <br /> MC S-02 <br /> rev:6/03,12/10 <br />