EXCAVATION/GROUND DISTURBANCE PERMIT
Project Number:
Project Name:
Date
/
Month
/
Day
Year
Date
Work Performed By/ Responsible persons:
Location of Excavation:
Reason for Excavation:
Start Date:
/
Year
/
Month
Day
Date
Present in Excavation Area:
Water
Sewer
Gas
Power
Fire Lines
Process Lines
Other
Special Precautions/Requirements (Check Those That Apply):
Oxygen monitoring
Explosions testing
Gas/ fume testing
Standby
Hand excavate at utility crossing
Grounding of tools
Barricades
Special Clothing
Other
COMPETENT PERSON CHECKLIST
Excavation Competent Person:
Superintendent of Excavating Sub:
Soil Type Classification:
A
B
C
Stable Rock
Have all procedural requirements been met and documented?
Yes
No
N/A
Is the excavation close to utilities, buildings, footings, pillings, sources of vibration?
Yes
No
N/A
Have utilities, etc. been located?
Yes
No
N/A
Has a check for the previous excavations in the area been made?
Yes
No
N/A
Have adequate supplies of equipment, PPE, shoring materials, signs, barricades, machinery, etc. been assured and checked?
Yes
No
N/A
Size of Excavation
Depth:
Width:
Length:
Slope will be:
Do vehicular and machinery operation patterns need to be changed?
Yes
No
N/A
Will water removal operations/equipment be needed?
Yes
No
N/A
Have trench boxes or trench shields been checked?
Yes
No
N/A
Entrance/exit means (maximum travel distance to exit 25 ft. (7.62 m)
Stairway
Ladders
Ramps
Note: Sloping/benching for excavations deeper than 20 feet (6.1 m) must be designed by a PE.
Competent Person Signature
HSE Representative obtain this signature last
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