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,vEnMARION COUNTY PUBLIC WORKS EZE <br /> BUILDING INSPECTION DIVISION AEG 18 2923 <br /> 5155 Riverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 ��` �j`�p�� <br /> http://pablicworks.co.marion.or.us/building/ Bt. I <br /> SEPTIC TANK ABANDONMENT FORM <br /> 5 <br /> THE SEPTIC TANK AT: l <br /> 5L WO ro ' I re. SE <br /> ACTIVITY NUMBER: 5 J 5-2 ✓ G o 12 3 l <br /> WAS PUMPED BY: C9 r j y J 2 J 1';G <br /> DEQ License# <br /> DATE TANK PUMPED: o7 z a 7 3 <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- 4oLt'd/7 1/rgll h <br /> SIGNED: ` DATE: / 15 3 <br /> MCS-02 <br /> rev:6/03,12/10 <br />