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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 /> SEPTIC TANK ABANDONMENT FORM <br /> r� <br /> THE SEPTIC TANK AT: 2 3S 7 ciON t, V161-P" E, _ <br /> ACTIVITY NUMBER: ) 9 -- 00 t 10 <br /> WAS PUMPED BY: 11,4 N {� w vk S R6 1-+Lot O�•y1 <br /> DEQ License# / I t S y4 C w h yn6 tid U.ct -e U C►t1 <br /> DATE TANK PUMPED: 9 i S 1'Uo ' Q N 1 !eH/ / ^ 'ZrJ <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> ory k wva itd <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 AME: . // �' L ( <br /> SIGNED �_ -DATE: y7' /I <br /> MC S-02 <br /> rev:6/03 <br />