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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> �~� �� 5155 Silverton Rd NE <br /> INN <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 /> THE SEPTIC TANK AT: 93O i l/V er F .. <br /> 0 //i Alter SC <br /> v //.0e, , 4 9 7.5 i <br /> ACTIVITY NUMBER: 555 - 0 —10&5' <br /> WAS PUMPED BY: &2,r -5 -4° 4(_, L L <br /> DEQ License# gq <br /> DATE TANK PUMPED: t / / /, 0 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> pot 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 /> p4 CRUSHED ROCK <br /> COMPANY NAME: M IAA ` i €..S 'LQ,ryl <br /> SIGNED: Vzpviett DATE: 1/13 /23 <br /> MC S-02 <br /> rev:6/03,12/10 <br />