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,'h m'luniW Development <br />BuildJn6 Inspectt~r, Division <br />Marion County <br /> OREGON <br /> <br />P.01 <br /> <br />~.PTIC_TANK ABANDONMENT <br /> <br />THE SEPTIC TANK AT: <br /> <br />WAS PUMPED BY: <br /> <br />DATE TANK PUMPED: <br /> <br /> (licensed D~E.Q.~pumper) ' <br /> <br />THE TANK WAS: L~.~ ~> <br /> REMOVED A~~ <br /> <br /> FILLED <br /> (note: the bottom of the tank should be per- <br /> <br /> tion of surface water in the tank) <br /> <br />FILL <br /> <br />MATERIAL: <br />[ ] REJECT SAND <br />[ ] BAR RUN GRAVEL <br />[ ] CRUSHED ROCK <br />[ ] OTNER: <br /> <br />ENCLOSE A <br /> <br />SIGNED: <br /> <br />PERMIT #: <br /> <br />SITE #: <br /> <br />COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> DATE: <br /> <br />(503) 588-5147 Senator Buildin$ 2nd Floor <br /> 220 High SI, NE. Salem, OR 97301-3670 <br /> <br /> <br />