Trenching & Excavation Permit
Permit Status
Open
Closed
Cancelled
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Competent Person Name
First Name
Last Name
Email
example@example.com
Project Name
Did you complete a paper Permit for this job?
Yes
No
Take a photo of the paper permit
Take Photo/Share File
Cancel
of
Location/Type/Description of Excavation
Provide detailed information
Equipment Operator(s)
Approximate Excavation Size
Controls
Will workers enter trench?
Yes
No
Atmosphere Checks
Oxygen shall read between 19.5% and 23.5%
LEL must read 0%
Means for Egress
Stairways
Ramp
Ladder(s)
Other
Soil Type
Stable Rock
Type A: clay, silty clay, sandy clay, and clay loam
Type B: cohesive and has often been cracked or disturbed
Type C: granular soils in which particles don't stick together well
Before Excavation
Rows
Yes
No
One call been performed
Overhead and underground utilities been identified and marked
Owners of utilities, service, or transmission piping been identified (electrical, telephone, water, sewer)
Pilings will be set back at least 18 inches
Changing ground condition(s) anticipated (particularly after rain fall)
Monitor for possible oxygen deficiency or gaseous conditions
Adequacy of shoring and/or sloping as work progresses
Water removal equipment available if needed
Portable trench boxes or trench shields available if needed
Check for previously disturbed ground conducted
Adequacy of all equipment, including personal protective gear, shoring material, signs, barricades, and machinery
Proper sloping
Excavations over 5' feet in depth
Rows
Yes
No
Sloping and benching adequate
Timber shoring for trenches
Aluminum hydraulic shoring for trenching
Alternative to timber shoring
Selection of protective systems
Designed shoring (data must be filed on site).
Is trench deeper then 20' feet? Note: Sloping or benching for excavations greater than 20 feet (6.1 meters) deep must be designed by a registered professional engineer.
Measures taken where the above conditions are not achievable
Acceptance
Site Manager(s) Name(s)
Competent Person(s) Name(s)
Equipment Operator(s) Name(s)
Entrant(s) Name(s)
Submit
Should be Empty: