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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> NM <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: "-err" <br /> 1-) lQ(WarAbwcn �J C <br /> t <br /> CD 12 <br /> ACTIVITY NUMBER: SO- EDOLAI <br /> WAS PUMPED BY: c‘cV- ,f\C. ajrr C <br /> DEQ License# � <br /> DATE TANK PUMPED: 1 t tO - DC)t3 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> 1,4 REMOVED <br /> C} 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 /> t] CRUSHED ROCK <br /> COMPANY NAM WE. 6- T a tv Ti a0.> 1-*IL <br /> SIGNED: DATE: 5- 15 . <br /> me <br /> rev:6103,l2?1 Q <br />