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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION ® E ELivEnn <br /> --%: � 5155 Silverton Rd NE <br /> • <br /> 111111 Salem OR 97305 �o�� <br /> (503)588-5147 FAX(503)588-7948 <br /> LI-j <br /> bttp://publicworks.co.marion.or.us/building/ SUM AR' N couN <br /> Ca INSP TY <br /> CTION <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 8 1 I v k) Q L Q yI Ci q act\ f <br /> ACTIVITY NUMBER: S 5 -Ii- ooiLt9F <br /> WAS PUMPED BY: C R r 1 S S tp k 1 <br /> DEQ License# 1 6 Z J 11 <br /> DATE TANK PUMPED: 07 ) 2.1 <br /> 2.. <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 N 41.Pon Drqi 1� <br /> SIGNED: DATE: C g/ " Z <br /> MC -02 <br /> rev:6103.12/10 <br />