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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <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 /> 2 <br /> THE SEPTIC TANK AT: el _s Lam. 1c5r <br /> ACTIVITY NUMBER: .5SS Z 3— n®Sei5'Z P t/i 17 <br /> WAS PUMPED BY: <br /> v � - <br /> DEQ License# 9114 079 <br /> DATE TANK PUMPED: /) I 11 k7 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] 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 /> CRUSHED ROCK <br /> COMPANY NAME: 1S d4 <br /> SIGNED: DATE: <br /> sic s-02 <br /> rev:6/03,12/10 <br />