Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> ,,,441kutafit. <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> • - <br /> Salem OR 97309-5036 <br /> (503) 588-5147 FAX(503) 588-7948 <br /> http://publicworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 8538 5:11v--e/T--1-A115 ibivA <br /> Ahrl%/1( <br /> ACTIVITY NUMBER: 55 - CI 003G C„8 <br /> WAS PUMPED BY: ( - <br /> DEQ.License# 14 71 <br /> DATE TANK PUMPED: 1\16i rOm 20 19' <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [1 REMOVED <br /> g. 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 /> [J CRUSHED ROCK <br /> not--1-1\p-e, 1/433,i1 otr‘a <br /> COMPANY NAME: On- 5;Le s4-cc ocr atia.+1 <br /> SIGNED: A rit.7ETNZ • DATE: Hay a 2oi <br /> MC S-02 <br /> rev:6/03 <br />