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HomeMy WebLinkAboutLateralPermit Lateral Permit Application P O Box 1130 Oshkosh, WI 54903-1130 Phone: (920) 236-5050 www.oshkoshwi.gov Project Address ________________________________________________________________________________________ Owner / Tenant Name__________________________________________________ Phone___________________________ Address_____________________________________________ Email______________________________ Contractor Company Name__________________________________________ Phone____________________________ Contact______________________________________________ Email_______________________________ Address________________________________________State Credential #’s__________________________ Master Plumber or Utility Cont. Lic # Type □ New □ Repair □ Abandon Use □ Residential □ Commercial Lateral Information Project Description ________________________________________________________________________________________ ________________________________________________________________________________________ Value of Job $ ____________________ (Value for materials & labor is req. to ensure consistency in accessing permit fees for all applicants.) Payment by: □ Check #________________ □ Cash □ Credit/Debit Card (office or online only) I certify the above information is complete and accurate. Any deviations from the above submitted information may require ad ditional permits to be obtained. I acknowledge and agree to these terms. Name: _____________________________________________ (Please print) Date: _______________________ Master Plumber / Utility Contractor Signature: ___________________________________________ Sanitary Sewer #1 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Sanitary Sewer #2 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Sanitary Sewer #3 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Storm Sewer #1 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Storm Sewer #2 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Storm Sewer #3 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Water Service #1 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Water Service #2 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main Water Service #3 Size: ________(") Material: □ Concrete □ Iron □ Plastic □ Vitrified Clay Type: □ Lateral □ Main