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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> Salem OR 97309-5036 <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: 121J' 3 s+ S e <br /> . iisv l or 9-73R-I <br /> ACTIVITY NUMBER: L535 2Z)9 <br /> WAS PUMPED BY: 4- (( <br /> DEQ License# L.0 gs1`3 <br /> DATE TANK PUMPED: — 2 I <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [LY 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: L./9,r_ pi - c 5 <br /> SIGNED: �� �—✓ • DATE: F ( [ <br /> MC S-02 <br /> rev:6/03 <br />