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O!dicorc <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 555 Court St NE/PO Box 14500 <br /> Salem OR 97309-5036 <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: 0 /'1 �a L3e i( 12 i <br /> 34. You <br /> ACTIVITY NUMBER: / XCI "�11 <br /> WAS PUMPED BY: f (' E ce'f4-(7C--- <br /> DEQ <br /> License# 56 (5 <br /> DATE TANK PUMPED: 5— / 7 — 19 <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED <br /> .kr FILLED <br /> CNOTE: 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 /> [] CRUSHED ROCK <br /> o. <br /> COMPANY NAME: Klet= C . _ cej <br /> SIGNED: Ota DATE: cits 19. <br /> MC S-02 <br /> rev:6/03 <br />