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MARION COUNTY PUBLIC WORKS <br /> ..-•••••.70 BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> 11111 Salem OR 97305 <br /> (503) 588-5147 FAX(503)588-7948 <br /> http://publicworks.coanarion.anus/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: V3 676 ittd.LAJC.Ve.Sk' <br /> Oi q 7 3 1 <br /> ACTIVITY NUMBER: S SC- z1/- 4'c <br /> WAS PUMPED BY: E -0 7CP0 ( <br /> DEQ License#• 2- / 36 .1 <br /> DATE TANK PUIVIPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORK <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 /> [.1 BAR RUN GRAVEL <br /> [] CRUSHED ROCK. 50/ <br /> COMPANY NAME: Ke 77-)0.2c.. <br /> SIGNED: L. L DATE: 8 - 1 - <br /> MC S-02 <br /> rev:6/03,12/10 <br />