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MARION COUNTY PUBLIC WORKS. <br /> BUILDING INSPECTION DIVISION <br /> -Ns 5155"Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948, <br /> http://publieworks.co.marion.or.usibuildingi <br /> SEPTIC TANK ABANDONMENT FORM. <br /> THE SEPTIC TANK AT:: qt5- Mcw 14-4-v4P 7,›R- <br /> 0- <br /> ACTIVITY NUMBER: 2g-oolq <br /> WAS PUMPED BY: PA-emosts been <br /> DEQ License# pea 0/ I <br /> DATE TAMC.PUMPED: 1 /7/Z4 <br /> ENCLOSE A COPY OF nit PUMPING RECEPT: WITH THLS FORM. <br /> THE TANK WAS:- <br /> p4 REMOVED <br /> [] FULLED <br /> (NOTE:..The bottom of the tank should beyerfbrated or cracked to prohibit the <br /> accummation of surface Water in the tank) <br /> FILL-MATERIAL: <br /> Ij REJECT SAND. <br /> • <br /> ,BAR RUN GRAVEL • <br /> [] CRUSHED ROCK <br /> COMPANY NAMESI : 0.49/wt • Cooltri/oh&L. LL C_. <br /> . DATE: 06/07/24 <br /> MCS-02 <br /> rtIrrfilb.12/10 <br />