Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> _ ems ; 5155 Silverton Rd NE <br /> MIII Salem,OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http:/hnublieworks.co.marion.or.us/buildini/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> /J-A <br /> THE SEPTIC TANK AT: I c 6 g 6 o u ct l <br /> ACTIVITY NUMBER: • <br /> WAS PUMPED BY: <br /> DEQ License# / <br /> DATE TANK PUMPED: ' /N!a 3 <br /> e,xe tali k Lila,/ so O/ eile7e 4i�f <br /> ENCLOSE A COPY OF THE PUMKING RECEIPT WITH THIS FORM. <br /> (g I-Gala- ( e c.e,S o f ft. <br /> THE TANK WAS: <br /> Mi 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 /> [] RESECT SAND <br /> [] BAR RUN GRAVEL <br /> • [] CRUSHED ROCK <br /> COMPANY NAME: G f'up'/ <br /> SIGNE - DATE: C'0ll6p �1 <br /> G:\Fomms‘SepttdS-02 A6andoemeat Potm.doc <br /> rev:6/03,12/10 <br /> ' l <br />