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c <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> ��`- Z <br /> Salem,, OR 97305 <br /> MN (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: '77 9 0\(\ . 1.—Q, r <br /> ACTIVITY NUMBER: (E `a'O tz (4-13(.. <br /> WAS PUMPED BY: F E ,42.4AA 4411 _-= c_ c o <br /> DEQ License # <br /> j <br /> DATE TANK PUMPED: "1 fl �i a <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> W 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 N --�INNA- L ,,\\,_„ .‘ k.C-l i- <br /> SIGNED n :4 - -7,7-c---- -1-1 ' -----11,./ DATE:- / - DATE: -1 I I 0 ( L B <br /> ,,.� 1 -- <br /> G:\Forms\Septic\S-02 Abandonment Form.doc <br /> rev:6/03,12/10 <br />