Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> Ai,"'' ,„„4 BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305' <br /> LIMN (503) 588-5147 FAX(503) 588-7948 <br /> irk://publicworks.co.marion.or.us/building <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 0Co .27 Hwy 99:6 <br /> Auras& OR f 5'700 2 <br /> ACTIVITY NUMBER: a/—lea 7 / 0 / <br /> WAS PUMPED BY: 4. had no r ,ole,74,L. <br /> � <br /> DEQ License# I n /T, <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> yt 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 /> A [I REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: D[—G e bn S ru c-71/0a L L C <br /> SIGNED: VD C4A... , DATE: /^ 2 9- o Z.2 <br /> G:\roans\SepticWORMS\S-02 Abandonment form doc NC: S-02 <br /> rev: 6/03, 8/10. <br />