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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Sliverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 FAX (503) 588-7948 <br /> htip://publicworks.co.marian.or.usfbuildingi <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: i0 c Oalk 5 <br /> tei4c (,) <br /> =;1 <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: <br /> /A),./ Co/V34f,tc.,4.)1 / C <br /> DEQ License# <br /> DATE TANK PUMPED: fbiff 2 3 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> •wgggsv-, „ „ <br /> THE TANK WAS: - <br /> aireqUiiii*go Mg' <br /> REMOVED A-wmfei,00410.,r .4. „„ <br /> " i'44P; V44M;ZOr'l <br /> 2411150101Y6410711644,i5 "1:WliAM:41111401iftWaillit' <br /> {1 FILLED 'w-Flof."-'4'4K::::1110,00.40,1111111110;7104.00,',*;',:%43011.4045,101011111111T: <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 /> . [I BAR RUN GRAVEL <br /> CRUSHED ROCK <br /> : . <br /> ZZC, <br /> COMPANY NA E: ird'u et av <br /> DATE: 40/1 /2-3 <br /> „,„ . <br />