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.�� MARION COUNTY PIJBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE • . <br /> - Sateen OR 97305 - • <br /> 4- t.-=t-,¢ ; (503)588-5147 FAX(505)588-7948 • ' • <br /> -http://pnblicworks.co.marion.or.nsibuilrlingl • • <br /> ' ' ' •• SEPTIC TANK ABANDONMENT FORN,t • <br /> • <br /> •. THE SEPTIC TANKAT: ' . 35.1/0',5 ;(2uY1-1•- 57`'SE ' • . . <br /> • . .Lypns;• .(ar 9'.35,3 . • <br /> . ' ; ACTIVFIYNUMBER: ,1.58-2,t-C?v I y 5.3 • <br /> • ' <br /> VIAS PUMPED BY: J/ $c2r) Sr•r vic:�5, id—4- • • • <br /> -.DEQ License#• '3�1:.2%2-• • <br /> • <br /> DATE TANK PUMPED: • m�4 2J1-ea z/ <br /> •INCLOSE A COPY OF°M:E PUMPING RECEIPT Wit1�.THIS FORM. - • <br /> TIB TANK WAS: ; <br /> ' <br /> • {JD <br /> (NOTE:The bottoria of the tank should be perfnrate'd or cracked to prohibit the <br /> • •• • accumulation of surface water in the tank) ' <br /> • <br /> • • •[J . REJECT SAND ' • ' - ' <br /> • []• .BAR RUN GRAVEL . • <br /> • <br /> • <br /> • ['J: CRUSHED ROCK • • - • <br /> COMPANYNA1viF33 S0r! : •a}`-v,G.....Si i,4.- , - . . • - <br /> SIGNED: '���% DATB.60 ,- 1 m�1 <br /> MC 2-02 . <br /> • m9:6/03 - • <br />