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.` MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> „ • 5155 Silverton Rd NE <br /> .111111111 Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> littnpublicWorks.to.mnrion.or.usIbuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC.TANK AT: ssac( <br /> ACTIVITY NUMBER.:WAS PUMPED PUMPED BY: CarkS r. <br /> DEQ License# <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT wail THIS FORM. <br /> THE TANK WAS: <br /> EL <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 /> {I. REJECT SAND <br /> {I BAR RUN GRAVEL <br /> CRUSHED ROCK <br /> Affordable Septic Systems <br /> 32948 Brewster Road <br /> COMPANY NAME: Lebanon OR 97355 <br /> SIGNED: DATE: <br /> MC S-02 <br /> rev:6/03,12/10 <br />