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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> %, 5155 Silverton Rd NE <br /> MIN 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: P"VeS WA11 LN" SE <br /> Igetkr. Opt_ <br /> ACTIVITY NUMBER: SSS' 2.2-Ooo (D54 <br /> WAS PUMPED BY: I I 0Pk-c- <br /> DEQ License# JBM <br /> DATE TANK PUMPED: 212 I /2VL2 <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: 0 r ' 0 OR 4f1X,11.o <br /> DATE: 2-2- 2-D1Z- <br /> MC S-02 <br /> rev.6/03,12/10 <br />