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• <br /> 3 s- z <br /> MARION COUNTY PUBLIC WORKS 05 Q • <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem, OR 97305 <br /> (503) 588-5147 FAX(503)588-7948 <br /> http://oublicworks.co.marion.or.ns/buildine/ <br /> SEPTIC TANK-ABANDONMENT FORM • <br /> • THE SEPTIC TANK AT: 37- 5L-1 '110tcie VutIN1 d r, • <br /> • TurtAze '17 .3 72- <br /> 1 <br /> • ACTIVITY NUMBER: GINIA- <br /> WAS PUMPED BY: 51)4}nr/- <br /> DEQ License# <br /> _DATE TANK PUMPED: <br /> /ol • <br /> • <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. '‘ <br /> THE TANK WAS: <br /> to <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 RO • <br /> COMP )1:1 [ tri C. '?0-1Y/r—' <br /> SIGNED: • DATE: <br /> G:\Forms\Scptic\S-02 Abandonment Form.doc <br /> rev:6/03,12/10 <br /> " <br /> .--• - T • <br /> . <br />