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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: 36 i- c i D <br /> l ©R 17le <br /> ACTIVITY NUMBER: f. 541- do olt f 3 <br /> WAS PUMPED BY: :i2A fr- (1 >l <br /> DEQ License# Tii 671 <br /> 6 <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] 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 /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> 1 ( 0 1- Co,G(ek. <br /> COMPANY NAME: (1, c 1 <br /> SIGNED: G�. DATE: <br /> MC S-02 <br /> rev:6/03,12/10 <br />