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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://publieworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: /4/O 41 Gt- GA 0' <br /> ACTIVITY NUMBER: I — 00 ' 71 ? <br /> WAS PUMPED BY: ("7./1 r '$ S'e`- <br /> DEQ License# 3 9/ U V <br /> DATE TANK PUMPED: L/ —S —) cj <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> Ike 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 <br /> [] BAR RUN GRAVEL <br /> 14 CRUSHED ROCK <br /> COMPANY NAME:E24t4 <br /> SIGNED: A -DATE: �� � / / <br /> MC S-02 <br /> rev:6/03 <br />