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MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> iiii-.--�,!%��� 5155 Silverton Rd NE <br /> Salem OR 97305 JUL 02 2014 <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: 7g$47 ity Of fi &AM li .0 /th <br /> S'Lv 7"`U OP- ?7rk <br /> ACTIVITY NUMBER: ,6-6-45-- 2 f-6O/ <br /> WAS PUMPED BY: (3-iz1c �'G L6 <br /> f <br /> DEQ License# a9i/r <br /> d <br /> DATE TANK PUMPED: �.-Zfr V <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> [] FILLED <br /> (_'"P'T., /� /DMC2- <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: GL /.v ,- A(I A-1-i 16, /1v <br /> SIG ,1 y .� DATE: r/72y <br /> 5A, <br /> 10 <br /> MC S-02 <br /> rev:6/03,.12/10 <br />