Laserfiche WebLink
MARION COUNTY P UBLIC WORKS - • <br /> _ • BUILDING INSPECTION DIVISION • <br /> ire • alll::..- <br /> 5155 Silverton Rd NE • <br /> Salem OR 97305 <br /> (503) 588-5147 FAX(503) 588-7948 <br /> - http://publicworks.co.marion.oras/building/ <br /> • <br /> SEPTIC TANK ABANDON ENT FORM <br /> • <br /> THE SEPTIC TANK.AT: t07 PA 7;z,-- r>. <br /> i4 <br /> AU-S VI LCA 92 97325- <br /> 1 <br /> ACITVITYNUMBER: c615-3— /7— s—70 <br /> WAS PUMPED BY: • M2M1/2..5 5:71e, L <br /> - -DEQ License# Syo7 <br /> DA'Z'E TANK.PUMPED: • /2/2//9 <br /> • <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT Witli THIS FORM. <br /> THE TANK WAS.: <br /> [] REMOVED. <br /> [I` FILLED <br /> y AP <br /> oGcs�� /u pL <br /> (' NO'1E: The bottom of the tank should be perforated or cracked to prohibit the <br /> accumulation of surface water in.the tank) <br /> FELL MATERIAL: - <br /> • <br /> [] REJECT SAND • <br /> [] BAR RUN GRAVEL = <br /> [] CRUSHED ROCK <br /> NA-'r' - <br /> COMPANY NA P: 44(AItAVA-fiNa.( PVC, <br /> • ,SIGNED9 tG - -DATE: 4/ �,5 /� <br /> MC S-02 • <br /> rev-.6/03 - • • <br />