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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> OM. Salem OR 97305 <br /> (503)588.5147 FAX(503)588-7948 <br /> http://publicworks.coanarion.orms/bading/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 18 u4, Od.), LJ Ay 5E <br /> q 7392 <br /> ACTIVITY NUMBER: Z 47'io <br /> WAS PUIVIPED BY: Ee.o, :21-N <br /> DEQ License# 34r361 <br /> — <br /> DATE TANK PUMPED: 26zt/ <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> REMOVED <br /> [I 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 /> COMPANY NAME: 72-20 c /.3 D <br /> SIGNED I LeiL 6dcre•teu DATE: 7 Ze -ZY <br /> MC 5-02 <br /> 'rev:6/03,12/10 <br />