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JUN 27 PH 3:09 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> —z5---------s- " 5155 Silverton Rd NE <br /> IIIIISalem OR 97305 <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: J 1 10 36,4!-Ave, SC <br /> &(c'w t. OR 9 3l7 <br /> ACTIVITY NUMBER: c <br /> WAS PUMPED BY: /\( Se -h G t- e n 6c%vett 1 <br /> DEQ License# TniF <br /> DATE TANK PUMPED: SM 8/19 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> d 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. 'g: '_t! ► C� <br /> SIGNED: DATE: V/. 7 <br /> trwroor- - <br /> MC S-02 <br /> rev:6/03,12/10 <br />