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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://publicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> • <br /> THE SEPTIC TANK AT: /// <br /> ACTIVITY NUMBER: / C°016 .3 L/ <br /> / <br /> WAS PUMPED BY: /4 a3 !� <br /> DEQ License# d <br /> DATE TANK PUMPED: ¶ ` /r /9' <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <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 /> kr REJECT SAND <br /> [] BAR RUN GRAVEL <br /> [] CRUSHED ROCK <br /> COMPANY NAME: ILI I;J c X04 (C J / <br /> SIGNE I: DATE: S <br /> MC S-02 <br /> rev:6/03,12/10 <br />