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CERTIFICATION OF TANK DECOMMISSIONING
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Parcel number 01 t L-( Ot: )
Address SR -) 12(ett-- 24 "76,04;
Property Owner Name1 +- MAI4 PAILIVS C
Septic Permit# (if applicable)
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Individual/Company Certifying Abandonment
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Phone Number 3oo M%-a•
I certify that all sewage was removed from the septic tank and/or pump chamber
on the above referenced site by a Jefferson County Certified Septic Tank
Pumper,4e-lid ilie-lieFwas-ertml.teei-ethe tank filled with soil or gravel.
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I certify that the septic tank and/or pump chamber on the above re V renced site
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has been decommissioned to Washington State and Jefferson County Public (lits4 fr.
Health Requirements.
.ALf Afi gl Z.- (
si. Date
Pri"W 12- I\LAPI1E6sL
Pump receipt attached
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