6601084_QMC_Ground Disturbance Permit

EXCAVATION/GROUND DISTURBANCE PERMIT
Trenching and Excavation Procedure HSEOP-05-01

This permit must be completed by a Competent Person before the start of any ground disturbance, trenching, or excavating.
Project Name and Number:
Company:
Contractor Drawing Reference Page #(s): (if applicable)
Work Area:
Location of Excavation:
Reason for Excavation:
Start Date:

YearMonthDay
Date
Permit Expiration Date:

YearMonthDay
Date
Name of Competent Person Responsible for Excavation:
Competent Person Phone Number:
Utilities Present in Excavation Area: (select all that apply)

Other
Utility Comments: (optional)
Special Precautions/Requirements: (select all that apply)

Other
Special Precautions/Requirements Comments: (optional)
COMPETENT PERSON CHECKLIST
Soil Classification:
Have all procedural requirements been met and documented?
Is the excavation close to utilities, buildings, footings, pilings, or source of vibration?
Have underground utilities been located?
Has a check for previous excavations in the area been made?
Have adequate supply of equipment, PPE, shoring material, signs, barricades, machinery, etc., been verified?
Are any other obstructions or hazards present? If so, describe them below: (optional)
Do vehicular and machinery operation patterns need to be adjusted for excavation?
Will water removal operations/equipment be needed?
Have trench boxes or trench shields been checked?
What type of entrance/exit means will be implemented? (max. travel distance to exits should be 25 feet or less)
Note: Sloping/benching for excavations deeper than 20 feet need to be designed by an engineer.
Slope of excavation will be:
Depth of Excavation:
Width of Excavation:
Length of Excavation:
Any Additional Comments on Excavation: (optional)
Date:

YearMonthDay
Date
Competent Person Name:
Competent Person Signature:
Superintendent Name:
Superintendent Signature:
Client Representative Name: (if in an operating facility, optional)
Client Representative Signature: (optional)
NPCL HSE Representative Name:
NPCL HSE Representative (obtain this signature last)
Should be Empty:

EXCAVATION/GROUND DISTURBANCE PERMIT

COMPETENT PERSON CHECKLIST

Note: Sloping/benching for excavations deeper than 20 feet need to be designed by an engineer.