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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.us/building/ <br /> SEPTIC TANK..ABANDONMENT...FORM:. <br /> THE SEPTIC TANK AT: 3 o 95 ( oJe.li a to _ ._ _ _ <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY J&�' '�::h . 44 s e-edy <br /> DEQ License# <br /> • <br /> DATE TANK PUMPED: .7-3-21/ .. . . <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 /> �C] CRUSHED ROCK <br /> • <br /> COMPANY NAME:, � ; °' <br /> SIGNED: .. .. <br /> DATE: T'"8'-./.:�, <br /> MC S-02 <br /> rev:6/03,12/10 <br />