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MARION COUNTY PUBLIC WORKS <br /> �1,0,1P''°..-n . BUILDING INSPECTION DIVISION • • <br /> ,-•-.Y _ "_- 5155 Silverton Rd NE <br /> Ali;:—�� <br /> Salem OR973Q5 • <br /> • <br /> 3 • <br /> • (503)588-5147 .FAX(503) 588-7948 <br /> - http://publicworks.co.marion.or.us/btulding/ . - <br /> . ' ' ' • SF 'TIC TANK ABANDONMENT FORM . <br /> - THE SEPTIC TANK AT: • n c /® nr SE • . • • . <br /> • :5 - s.. .off`• ?? 1Y <br /> ACT VITYNTJMBER _ l co ?V/% — �,2�+�t 7- • <br /> . <br /> WAS PUMPED BY: . 1/f5oi S- ri 'S 1 U- ' ' • • ,_ <br /> • .DEQ License • •• 3, -2� ' <br /> DATE TANK PUMPED: • 6/2-2- 2 Z • • . • <br /> • •ENCLOSE A COPY OF TEA PIT IPING RECEIPT Wi't`H THIS FORM. ' • . <br /> IEEE TAl WAS: • <br /> • • [1. • REMOVED . ' ' . • ' <br /> MILLED . <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 /> • . • .[j . RE7BCT.SAND ' • <br /> .BAR RUN GRAVEL . <br /> . - [] : CRUSHED ROCK <br /> • COMPANY NAME: /4S S r <br /> oil a-rV2 9 5 L r -. <br /> M � . <br /> SIGNED: .�:%� 'DATE:. 6• 2S/ • • <br /> MC 3-02 <br /> rev:6/03 <br />