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Marion County <br /> OREGON <br /> <br />COMMUNITY DEVELOPMENT <br /> DEPARTMENT <br /> <br />Building Inspection Division · Community DEvelopment Center <br />285 Church Street NE · Room 132 · Salem, OR 97301-3670 <br /> <br />SEPTIC~TANKABANDONMENT <br /> <br />THE SEPTIC TANK AT: <br /> <br />WAS PUMPED BY: <br /> <br />(l~ensed D.E.Q. pumper) <br /> <br />.DATE TANK PUMPED: <br />THE T~AS: <br /> <br />[ ] <br /> <br />FILLED <br />(note: the bottom of the tank should be per- <br />forated or cracked to prohibit the accumula- <br />tion of surface water in the tank) <br /> <br />FILL MATERIAL: <br /> [ ] ~,~EJECT SAND <br /> [ &~- BAR RUN GRAVEL <br /> [ ] CRUSHED ROCK <br /> [ ] OTHER: <br /> <br />ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> <br />SIGNED :~~ <br />PERMIT : ~- O2~'? <br /> <br />abandon, tnk 4 / 9 5 <br />MC-15-S2 <br /> <br /> <br />