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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silver-ton Rd NE <br /> mu- <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: 2C) G42- - 2tU e, Ze) <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: V`tGc drt- S, <br /> DEQ License# Sao 7 C) <br /> DATE TANK PUMPED: Se P-i- , 2.o z 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: (4 C <br /> SIGNED: DATE: S'e Pc , t 0 lv2 <br /> Mc S-02 <br /> rev:6/03,12'10 <br />