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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 /> THE SEPTIC TANK AT: 107 Horeb St. Gates OR <br /> ACTIVITY NUMBER: 23-008672 <br /> WAS PUMPED BY: Oregon Sewer and Drain <br /> 38968 <br /> DEQ License# <br /> DATE TANK PUMPED: 10/31/23 <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 /> NeW:7174ri1067011667if old' <br /> COMPANY NAME: Flow Line Construction LLC <br /> SIGNED: /FG j 4 DATE: 11/28/23 <br /> MC S-02 <br /> rev:6/03,12/10 <br />