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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 111. 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: 716 rareva V e e Le 4 V c ,,P I/ <br /> ACTIVITY NUMBER: or 75.0 T <br /> WAS PUMPED BY: f .e,_ <br /> DEQ License# /L107( <br /> DATE TANK PUMPED: ail l /z)1 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> { [Y, 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 /> IA CRUSHED ROCK <br /> COMPANY NAME: 0414,4 hi <br /> SIGNED: 46.1 lvelAd DATE: <br /> MC S-02 <br /> rev:6/03,12/10 <br />