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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> mg— <br /> Salem 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: Z t I �-+4 / /bre- <br /> (DaTA 1 C2i R C -731* <br /> ACTIVITY NUMBER: �� 7 - - / - CO mac' <br /> WAS PUMPED BY: CC.YI St ttJGic d-' Ora v� LL& <br /> DEQ License# CJ� Z <br /> DATE TANK PUMPED: t/--7J1--7 r) <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> 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 MATERIAL: <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: I r_ <br /> SIGNED: DATE: 1-7-2-1 <br /> �' _ <br /> MC S-02 <br /> rev:6/03,12/10 <br />