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• <br /> MARION COUNTY PUBLIC WORKS <br /> • ICfrr BUILDING INSPECTION,DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> ..; Salem OR 97309-5036 <br /> (503)588.5147 FAX(503) 588-7948 <br /> hitp (/pubiicworks.co.ra ion or uslbui1 Thing/ <br /> SEFile TANK O NT FIRM <br /> TEE SEPTIC TANK AT: e/3 'SG - /t./ <br /> ACTIVITY NUMBER: . f010 -3 <br /> ETAS PUMPED BY: r /71/ S 7/iC <br /> DEQ License* _ 3 70 <br /> DATE TANK PUMPED: r _ <br /> ENCLOSE A COPY OF T.H.E:PUMPING RECUT 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 /> [J • REJECT SAND <br /> - I BAR RUN GRAVEL <br /> - CRIBBED ROCK <br /> COMPANY NAME ',.J <br /> #-(4e4,..74 / ,�/SIGNED: DATE;�llJ (� 0, � <br /> MC S-02 - • • <br /> rev:6/03 <br />