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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> ~ " v 5155 Silverton Rd NE <br /> imm--._._- --- <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: )14 l L`? /4112A vi— <br /> S,Itrr--✓-fr-,,, (Cry ~l'-f <br /> ACTIVITY NUMBER: 55 - 2- — a G`?b cif <br /> WAS PUMPED BY: L/Y°zf ec r�,,. d- D r ,-r LLC <br /> DEQ License# <br /> DATE TANK PUMPED: 12.- 1 1 -, . <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> til 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: GJ 'z. t <br /> SIGNED: DATE: (2- 12-75 <br /> MC S-02 <br /> rev:6/03,12/10 <br />