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14IARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Baleen,OR <br /> (503) 588-5147 FAX <br /> 97305(5 3)S88-7948 <br /> •! ubiicworks.co.mn "on.or.uxfbuildin <br /> htt�,. (D n gl <br /> SEPTIC TANK ABANDONMENT FORM <br /> { <br /> r <br /> THE SEPTIC TANK AT: ,`'� <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: <br /> DEO License# C <br /> DATE TANK PUMPED: L if t,?, -..`� <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> REMOVED <br /> k FILLED <br /> (NO'1•E: 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 /> (1 REJECT SAND <br /> ( ( .,"`} BAR RUN GRAVEL <br /> h CRUSHED ROCK <br /> COMPANY NAME: _.‘` ll c � . <br /> SIGNED _ DATE: j <br /> G.T 0418-02 Ab ra,,.aoo <br /> rtr.6413,12/10 <br />