Report 6 u/°ao /O -0o/ d
��aoSO"c SEPTIC TANK DECOMMISSION (ABANDONMENT)
?AV, For Onsite Sewage Disposal System
�^ Washington County Department of Health & Human Services
.''ts;
ar4 Environmental Health
°" & 155 North First Avenue, MS 5, Suite 160 • Hillsboro, Oregon 97124 -3072
Telephone: (503) 846 -8722
Please return completed form to Washington County Department of Health & Human Services
Environmental Health
1.
Township Range Section Tax Lot # (s)
2. " . r _�I C
Printed Name of Property Owner
rr _
3. The septic tank located at: 7 Z 0 5 w C `‘ v`�u- V- l ► .
����, Address City . State f •/ Zip Code
vvas pumped f sludge on:
Date: 1 ( /tb
By Licensed Operator: ._ License #:_ /0 j' — I
Jas backfillecj with sand or clean bank run gravel AFTER being pum. -d of ude - o .
Date: < 2:2 /e) Signature of Operator _ ,,,,
Oregon Adminlstrative Rules 340 71 185 Decamm m
issioning of Systems
1) The owner shall decommission a system when:
a) A sewerage system becomes available and the building sewer has been connected
thereto; or
h) The source of sewage has been permanently eliminated:
2) Procedures for Decommissioning:
a) The tank(s), cesspool or seepage pit shall be pumped by a licensed sewage disposal
service to remove all seepage;
b) The tank(s), cesspool or seepage pit shall be filled with reject sand, bar run gravel or
other material approved by the Agent, or the container shall be removed arid properly
disposed.
The septic tank at the address above h •:- • • 4 ecom - ' s sioned in accordance with Oregon Administrative
Rules.
Signature of Property Owner
WCDHHS El I
Revised April 2007
•
. .
• CITY OF TIGARD ......_
.'u 13125 SW Hall Blvd. I;
• 11 Tigard, OR 97223 q y
'l .��., 503.839,41
rte'' Inepeotlon Requests, 503.639,4175 .... ,..,. •?
UP2010•00184
1==M 020 SW CLINTON 8T
0=31111111111 ' emo of existing SFR �k
ontrootor
nspoatlon Roquost 8ohodulod For
usual 31, 2010
/A
99 Final inspection
18293•01 803.780.4918
- squeelore Phone .03.780.4918 (�
Result Comments
3I:WERCAP REQUIRED
MAKE' PHOV181ON8 f bti GUMI'LL' flbN OF TI IIS DEMO.
ART
- Iok Solon
=11111111111111 uguet 31, 2010
=MIN 503718.2424