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MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 FAX(503)588-7948 <br /> http:/ipublidvorks.co.mation.or.usibuilding/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: <br /> 5111"; ,Cr`, 43754f1 <br /> ACTIVITY NUMBER:. -1-606s2e( <br /> WAS PUMPED BY: irk141.4 ce.fif <br /> DEQ License# <br /> DATE TANK PUMPED: 11,420x01/1 61.444,,-1 0- 6 tele..etz5) <br /> -Ye 7-444.k. ieedeere hap$1-e.4-jd-5 &Ott 71"4&'Lk LA-1 AS eP7ett/ e <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. a,4 <br /> THE TANK WAS: <br /> [] REMOVED <br /> ,ley 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 Re fr-i---/tad,LN <br /> [1 BAR RUN GRAVEL <br /> [ CRUSHED ROCK <br /> cOMPANY NAME: av-ert 5134.,74.-- amwt 1-4-C <br /> SIGNED: DATE: 9-5- <br /> MC S-02 <br /> riv:6/03,12/10 <br />