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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> _j 5155 Silverton Rd NE <br /> Salem OR 97305 <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: 77,1 /1/,jvin fil/ # <br /> Sl- A/ /i? 57/37 <br /> ACTIVITY NUMBER: /('-02 12 k4 <br /> WAS PUMPED BY: /VPr I. y Env.jrn,-yam/ <br /> DEQ License# 37504 <br /> DATE TANK PUMPED: J„p / 7'I 'L,/A <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> X 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 MA T LRIAL: <br /> [] REJECT SAND <br /> [] BAR RUN GRAVE <br /> b4 CRUSHED (sett) • <br /> COMPANY NAME: At: / 4/W jgxc.;l/c7s-y✓ <br /> "„),-171 <br /> SIGNED: ��) -DATE: '!-jo-hi <br /> MC S-02 - <br /> rev:6/03 <br />