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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> II Salem,OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> httinfinublieworks.comarion.or.usibmiding./ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 240 Hill•Street • <br /> Detroit, OR 97342 <br /> ACTIVITY NUMBER: <br /> - WAS PUMPED BY: A&B Septic <br /> DEQ License II 38137 <br /> . DATE TALK PUMPED: 240 Hill Street <br /> • ENCLOSE A COPY OF'flit PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> D4 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 /> [j REJECT SAND <br /> [1 BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: 10 1.4N(Ntr <br /> SIGNED: DATE: --2--`1-2 Li <br /> 0:1Fonas1SeptidS40 Abandonment Form.doc <br /> • rev:6/03,12/10 <br />