Laserfiche WebLink
• <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Siiverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publicworks.co.marion.or.us/buiiding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: /12 9 Ika ol%Per St <br /> ACTIVITY NUMBER: 5s5�aL -00339�'PR 7 <br /> WAS PUMPED BY: Clan Eli* ',r �'i <br /> DEQ License# ° , �;;�� 1'14 <br /> DATE TANK PUMPED: S J I 2 f?T <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> j] REMOVED <br /> bif 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 /> 11,r CRUSHED ROCK <br /> COMPANY NA C 3/en Dr ;r <br /> • <br /> SIGNED: DATE: O 8/I2/2T <br /> MC 3.02 <br /> rev:6/03,12/10 <br />