HSEOP -05-01: Ground Disturbance Permit

EXCAVATION / GROUND DISTURBANCE PERMIT
Project # and Name
Work Performed By*
Start Date*

MonthDayYear
Enter Start Date of Excavation/Ground Work
Drawing:
Location of Excavation:*
Reason for Excavation:*
Permit Expires:

MonthDayYear
Please enter the date when the required permit is expired
Person Responsible for Excavation:*
Phone:*
Format: (000) 000-0000.
Signee Email
Please enter your email if you wish to receive a copy of your form upon approval
UTILITIES PRESENT IN EXCAVATION AREA
Water
Comments
Please comment any specific details in the box above
Sewer
Comments
Please comment any specific details in the box above
Gas
Comments
Please comment any specific details in the box above
Power
Comments
Please comment any specific details in the box above
Fire Lines
Comments
Please comment any specific details in the box above
Process Lines
Comments
Please comment any specific details in the box above
Other
Comments
Please comment any specific details in the box above
% O2Explosion testingGas/Fume testingStandby personHand excavate at utility crossingGrounding of toolsBarricadesSpecial clothingOther
Comments
Any comments on the above precautions/requirements can be written here.
Craft Supt. Of Craft Excavating*
Excavation Competent Person *
COMPETENT PERSON CHECKLIST
Stable RockType AType BType C
YESNON/A
YESNON/A
YESNON/A
YESNON/A
YESNON/A
Other obstructions/hazards blanks . Slope will be: blank Comments: Type a label
Size of excavation
Depth*
Width*
Length*
YESNON/A
YESNON/A
YESNON/A
StairwaysLaddersRamps
Competent Person Name/Signature *
Note: Every prefabricated, hydraulic or engineered support system shall be designed by a professional engineer. A copy of the drawing shall be provided to PCL.
Please use the dropdown list below to select the name of the PCL Approver and submit form for approval.
PCL Approver/Safety Representative*
Please Select the Name of the PCL Approver/Safety Representative and Submit form
PCL Approver Email
example@example.com
PCL Approval/Safety Representative Signature
Should be Empty:

EXCAVATION / GROUND DISTURBANCE PERMIT

UTILITIES PRESENT IN EXCAVATION AREA

COMPETENT PERSON CHECKLIST

Size of excavation

Please use the dropdown list below to select the name of the PCL Approver and submit form for approval.