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• <br /> MARION COUNTY PUBLIC WORCS - FF <br /> "'' BUILDING INSPECTION DIVISIOI) E L _ V <br /> am_ 555 Court St NE/PO Box 14500 1 <br /> Salem OR 97309-5036 <br /> • (503) � .8� 05 ?��� J <br /> 588-5147 FAX(503) 588-7948 <br /> http://publicworks.co.marion.or.us/buildinggMARION COUNTY <br /> B http://publicworks.co.marion.or.usibuildiIaON <br /> • <br /> • <br /> • <br /> SEPTIC TANK ABANDONMENT FORM <br /> • <br /> THE SEPTIC TANK AT: <br /> ACTIVITY NUMBER: 2-60,o - F-50QWAS PUMPED BY: r ! • <br /> • <br /> • DEQ License# ',„?'0#%/c <br /> • ; DATE TANK PUMPED: 44" <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. • <br /> • <br /> . THE TANK WAS: <br /> [] REMOVED <br /> • <br /> • , 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 /> • <br /> REJECT SAND <br /> [] BAR RUN GRAVEL <br /> • • • [] CRUSHED ROCK • <br /> • <br /> COMPANY NAME: / - <br /> • - SIGNED: /G, ` _!`1 DATE: <br /> MCS-02 . <br /> NV.6/03 <br />