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02/23/2023 11:10 5037691131 PAGE 01 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> "Zag` 5155 Silverton Rd NE <br /> 111111111 Salem OR 97305 <br /> (503) 588-5147 FAX(503)588-7948 <br /> http://publieworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: v 0►I 1C e1,0) <br /> ACTIVITY NUMBER: - 55 _" 23 --00/ 807 <br /> WAS PUMPED BY: r ) ci_ J e.01( <br /> DlQ License <br /> r.ense# 2) 10 <br /> DATE TANK PUMPED: \3 I <br /> 2: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> r] 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 /> r] REJECT SAND <br /> BAR RUN GRAVEL <br /> [ ] CRUSHED ROCK <br /> COMPANY a <br /> S <br /> SIGNED: DATE: Y`/3 a2, <br /> MC S-02 <br /> rev:6/03,12/10 <br />