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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Riverton Rd NE <br /> 1.1111 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: both 4L,-4-, Rd <br /> Tern d <br /> ACTIVITY NUMBER: Ph I <br /> WAS PUMPED BY: pre p 6re c- el" DOi 41 <br /> DEQ License# MI le <br /> DATE TANK PUMPED: 1?15/Z-3 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: -- <br /> AREMOVED w i I 6C <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: 64)ci GlerA tom.-►hg <br /> SIGNED: (?,,LA 4 DATE: <br /> Mc S-02 <br /> rev:6/03, 12/10 <br />