Ground Disturbance Permit

Excavation/Ground Disturbance Permit
Project
Your Cell Phone Number
So we can text you when permit is approved/rejected.Format: (000) 000-0000.
Email (copy of final permit will be sent here)
example@example.com
Date

MonthDayYear
Date
Company
Work Performed by:
Drawing:
Location of Excavation:
Reason for Excavation
Person Responsible for the Excavation
Start Date

MonthDayYear
Date
Permit Expires

MonthDayYear
Permit Expiry to be verified by Site Superintendent
Utilities present in the Excavation Area
Water Comments:
Sewer Comments:
Gas Comments:
Power Comments:
Fire Lines Comments:
Process Lines Comments:
Other Comments:
Special Utilities (Check all those that apply):
Other Special Utilities (Specify)
Additional Comments?
Craft Superintendent of Craft Excavating
Signature of Craft Superintendent
Client Representative (If in an operating facility)
Signature of Client Rep (If in an operating facility)
Excavation Competent Person
Signature of Competent Person
PCL HSE Representative
PCL Superintendent if no HSE Rep on site
Signature of PCL HSE Representative
Soil Classification:
Have all procedural requirements been met and documented?
Is the excavation close to utilities, buildings, footings, pilings, source of vibration?
Have utilities, etc., been located?
Has a check for the previous excavations in the area been made?
Have adequate supplies of equipment, PPE, shoring material, signs, barricades, machinery, etc., been assured and checked?
Additional obstructions/hazards:
List additional obstructions/hazards here
Other obstructions/hazards:
Slope Will Be:
Slope Comments:
Depth of Excavation:
Specify unit of measure
Width of Excavation:
Specify unit of measure
Length of Excavation:
Specify unit of measure
Do vehicular and machinery operation patterns need to be changed?
Will water removal operations/equipment be needed?
Have trench boxes or trench shields been checked?
Entrance/Exit means (maximum travel distance to exit 25ft/8m)
Competent Person
Date

MonthDayYear
Date
Should be Empty:

Excavation/Ground Disturbance Permit