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iiiljgggaWq <br /> 41 <br /> MARION COUNTY PUBLIC WORKS JAN 0 5 2018 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING NSPECTION <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: 65/ <br /> • <br /> eai., 9`7 99z <br /> ACTIVITY NUMBER: 555— /6. 005913 • <br /> WAS PUMPED BY: eLuLEiy_ %TLC, Tai-1-4 lite.2 y..2,,cp rue: . <br /> DEQ License# .370„1.x-{ <br /> DATE TANK PUMPED: I/36 <br /> 30 11 to <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> 1)] 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 /> N CRUSHED ROCK <br /> COMP• " AME: < a <br /> SIG • it ilk A- DATE: ‘I SI I <br /> MC S-02 <br /> rev:6/03 <br />