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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 1.11 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: gqrq f i2d 5 <br /> ACTIVITY NUMBER: 6 - <br /> WAS PUMPED BY: OvYro,t <br /> DEQ License# .3C1,6k <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> ti 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 /> [tc] REJECT SAND QL-t— <br /> [ ] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: <br /> SIGNED:• - � DATE: 1 Z-aLy <br /> MC S-02 <br /> rev.6/03,12/10 <br />