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- - <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948• _ <br /> http://publicworks.co.marion.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE.SEPTIC TANK AT: .3004• <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: 44--w-411- <br /> DEQ License4 <br /> DATE TANK PUMPED: <br /> 'ENCLOSE A COPY OF THE PUMPING RECEIPT VVITH THIS FORM. <br /> THE TANK WAS: <br /> II •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 /> 4 BAR.RUN GRAVEL <br /> 1[1 CRUSHED ROCK <br /> COMPANY NAME: 0/1-°"-t-4- p e sp, <br /> SIGNED: DATE: W-72,1 <br /> mc s-o2 <br /> rev:6/03,12/10 <br />