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4, MARION COUNTY PUBLIC WORKS <br /> "` BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> MO— <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 /> - -3(0 g COM i- <br /> THESEPTICANKAT: <br /> ACTIVITY NUMBER: JJ <br /> WAS PUMPED BY: °Veep/I tt. . A <br /> DEQ License# <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF 1BI 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 NAME: ` enn ) StuuyviPM4 aga...11A-440 <br /> SIGNED: DATE: <br /> k <br /> MC s-02VAIU W I - 101 0 l� <br /> rev.6/03 12/10 • I <br />