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�.. MARION COUNTY P UBLIC WORKS - <br /> Y_`'";;",,1-= • BBU DING INSPECTION DIVISION . <br /> - - 5155 SilTerEon Rd NEt <br /> - =. - - = SalemOR9-73Q5 _ - <br /> _: =-= (503) 588-5147 FAX(503) 58Q-7940 <br /> - - - http://pnblicworks.co.marion.or.ns/bro1dm-g/ - . <br /> • <br /> SEPTIC TANKABANDONIY NT FORM <br /> TEE SEPTIC TANK AT: _ 10 025,.. North --Pa k . L 1,1 e; .5. k' , <br /> - - . it 5 i O973 51 <br /> ACTIVIIYNUMBER: - _ --- <br /> • <br /> • WAS PUMPED BY: - r<ir w"ev•3 5e_?t k. C6. . <br /> • -DEQ License# .341 CO I . <br /> • <br /> Dkt B TANK PUMPRf: ' f Z - 2-3- zO <br /> ENCLOSE,4 COPY OF THE PUMPING RECEIPT wita THIS FORM. <br /> THE TANK WAS.: '. • . <br /> REMOVED. <br /> [1` FILED - - <br /> (NOTE: The bottom of the tank should be perforated or crackecLto prohibit the . <br /> accumulation of surface wafer in the tank) _,s <br /> FILL MATERIAL; - <br /> [] REJECT SAND <br /> [] BAR RUN GRAVEL . <br /> .[1 CRUSHED ROC1s . . <br /> •COMPANY NAME: S4 Li c�fi 61'a►M e S tic , . <br /> . • SIGNED: �• <br /> �.�'�%` DATE: 3-chte. 2 0 <br /> • <br /> MC S-O2 ' <br /> iev:6103 - <br />