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• <br /> MARION COUNTY PIJBLIC WORKS <br /> •••'' '.i3•0,.`- • BUILDING INSPECTION DIVISION ' • • <br /> `.- 5155 Silverton Rd NE <br /> • --: - Salem OR 97305 • <br /> ' (503)588-5147 `FAR(503)588-7948 . • • . <br /> • http://publicworkk.co.marion.or.us/btaldmg/ •• . <br /> ' • • •• SEPTIC TANK ABANDONMENT FOR1V <br /> • THE SEPTIC TANK AT:• • • ' •SS CA . G Ct'a & R-b.• <br /> . ;S CO-t- t_t_s ore_ <br /> . . • • ACTIVTTYNUMBER •I r U b 61 • <br /> WAS PUMPED BY: 14°N6 ST _ ,-1;44.'rr..� • o,t..u.•r'r-0 QS ` <br /> • 1 - ,DEQ License it <br /> AS • <br /> • <br /> • <br /> DATE TANK PUMPED: " • .. 1 S 1.-- 2..=a- I. . w . . <br /> • •INCLOSE A COPY OF THE PUMPING RECEIPT WITS THIS FORM. • , • _ <br /> THE TANK WAS: •• . _ . _ . . . - . . <br /> ' REMOVED • <br /> [I .FILLED . <br /> (NOTE:The bottom of the tank should be peaforatdd or crack ci to-prohibit the <br /> • •••• •• accumtdation of surface water in the tank) . <br /> • - FILL MATERIAL: - •• : •• • . • <br /> • , •[] . REJECT,SAND ' • _ <br /> • -• <br /> []• •BAR RUN GRAVEL <br /> • [] , CRUSHED ROCK • <br /> • <br /> COMPANY NAME:• .0 W p•0'T Q__ , - • <br /> SIGNED: .ter ' - --- ` .DATE:. " o ZO Z'Z <br /> • <br /> . MC s.02 <br /> rev:iiO3 _ . <br /> • • <br /> 1. a. <br /> ;- <br />