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f <br /> 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: 5j J7� �q ke Z4,'f f2 44 el' <br /> . 5 /4/Lk <br /> ACTIVITY NUMBER: ! ^ Ca? 1r6) <br /> WAS PUMPED BY: A CC <br /> DEQ License# <br /> DATE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> A(] 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 /> At CRUSHED ROCK <br /> COMPANY -e 14L <br /> SIGNED: - ��_ / '�► DATE: 1//94 <br /> 9 <br /> MC S-02 <br /> rev:6/03 <br />