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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://publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: 'giCiecf (2vv%si t aap 1?e 2 Spa' <br /> /W►a/.V, 014 `2-73at <br /> ACTIVITY NUMBER: S S - Go c �� <br /> WAS PUMPED BY: O fig L-LCr <br /> DEQ License# <br /> DATE TANK PUMPED: '-?G-�Y <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> j 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 /> [It REJECT SAND Pw4-- <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: I2v _ LLL <br /> SIGNED: DATE: / ' <br /> MC S-02 <br /> rev:6/03,12/10 <br />