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• <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> —1���"!�� 5155 Silverton Rd NE <br /> Salem,OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publicworks.co.marion.or.us/bufding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: iZcIler\ l 1n • <br /> ACTIVITY NUMBER: • <br /> WAS PUMPED BY: C .�'I� ,y(4 ' <br /> DE License <br /> DATE TANK PUMPED: RI 161 /29 <br /> ENCLOSE A COPY OF TILE 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 /> [j BAR RUN GRAVEL <br /> [j CRUSHED ROCK <br /> COMPANY NAME: (mLL) . <br /> SIGNED: C G� v` Pam' DATE: —2 2 <br /> G:IForms1Septic\S-o2 Abandonment Fonn.doc <br /> .•..•41f11 11.11A <br />