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s <br /> ` MA[UON COUNTY PUBI IC WORKS, <br /> . N .: k3UII:UINt INSPECTION ►IYISION <br /> 5155 Sttvertnn Hd E <br /> etu 97Q <br /> ml UR <br /> (503)588-51 7 FAX(SU3)a 8-7'I4 <br /> ,4. ' Itttp:!!pu@Iienorks,rb:rnanon:or us/bu1ld»g1 <br /> SEPTIC TANK ANlDf3NMEN1 FGtltM <br /> THE:SEPTIC TANK.AT <br /> ACTIVITY„NUMBER: . . <br /> � ;: ' WAS PUMPED BY <br /> DEQ I:rcense#•- <br /> 4 <br /> DATE TANIc;FUMPED <br /> 1� �� <br /> • <br /> 1 ENCLOSE A COPY OF THi PUMPING�ttECEIF f WITH THIS-FORM <br /> a <br /> :THE TANK WAS <br /> .REM t <br /> R O� <br /> .. .-... .,. _ FILL <br /> ^Y <br /> • <br /> s.. ted or cracked to prohibit the <br /> ;�NUTE::'The b tto fthe tag a perfo <br /> ,: k•sha <br /> ra <br /> accumulaiwn of surfac water m tank): 5 <br /> TER.IAL <br /> A V <br /> .. <br /> 7 <br /> �[:1 S RUN GRAVEL <br /> C] <br /> CRUSI�D R OCK f <br /> • <br /> Ct�MPANY N <br /> DATE 'j)2_E I'" �` <br /> SIGNED: <br /> • <br /> t tie s-oz• . <br /> sr= <br />