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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> = �i 5155 Silverton Rd NE <br /> Milli Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http://publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: ) L S lakYVW. 2_S <br /> Ve \-i - OC <br /> ACTIVITY NUMBER: <br /> WAS PUMPED BY: <br /> DEQ License# \( 9g6, <br /> DATE TANK PUMPED: 2 k1/7t( <br /> ENCLOSE A COPY OF IHL PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> ANC 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 ROCK <br /> COMPANY NAME: CC7 <br /> SIGNED: DATE: d h ti 7 <br /> ( _.?r,„ <br /> MC S-02 <br /> rev:6/03,12/10 <br />