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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <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: 57 S i4o5tere. Lc, 5(= <br /> At_.).-.,. sv . le OC •973a-S <br /> ACTIVITY NUMBER: S S S- PO -GOc G K T- P R A-lT <br /> WAS PUMPED BY: C_1 LL C c1' <br /> DEQ License# 31 l H <br /> DATE TANK PUMPED: <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 /> Affordable Septic Systems <br /> 32948 Brewster Road <br /> Lebanon OR 97355 r. <br /> COMPANY NAME: <br /> • <br /> SIGNED: DATE: '7- I a-a a. <br /> MC S-02 <br /> rev:6/03,12/10 <br />