EXCAVATION/GROUND DISTURBANCE PERMIT
Project Name:
*
Please Select
New Waterford Hub
Northside Health Complex
South Shore Regional Hospital
DCC Land Base
Ecole Halifax Peninsule
DCC 4ESR
DCC Ground Base
CRA Saint John Fit-up
Transition Centre
PEI Mental Health & Addictions
Work performed by:
*
Name of Company
Drawing #:
Location of excavation:
*
Reason for excavation:
*
Start date:
*
/
Month
/
Day
Year
Date
Permit Expires:
*
/
Month
/
Day
Year
Date
Person responsible for the excavation:
*
Phone Number:
*
Format: (000) 000-0000.
Utilities
Rows
Present in Excavation Area
Water
Sewer
Gas
Power
Fire Lines
Process Lines
Others
Comments:
Special Precautions/Requirements:
Rows
Check Those that Apply
% O2
Explosion testing
Gas/Fume testing
Standby person
Hand excavate at utility crossing
Grounding of tools
Barricades
Special clothing
Special Precautions/Requirements Other:
Comments on Special Precautions:
Craft Superintendent of Craft Excavating Name:
*
Craft Superintendent of Craft Excavating Signature:
*
Client Representative (if in an operating facility) Name:
Client Representative (if in an operating facility) Signature:
Excavation Competent Person Name:
*
Excavation Competent Person Signature:
*
HSE Representative Name:
*
HSE Representative Signature:
*
Competent Person Checklist
Soil Classification:
*
Stable Rock
Type A
Type B
Type C
*
Rows
Yes
No
N/A
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?
Other obstructions/hazards:
If Other obstructions/hazards list them:
Slope will be:
*
Slope Comments:
*
Depth in feet.
*
feet
Width in feet.
*
Length in feet.
*
*
Rows
Yes
No
N/A
Do vehicular and machinery operation patterns need to be changed?
Will water removal operations/equipment be needed?
Have trench boxes or trench shield been checked?
Entrance/exit means (maximum travel distance to exit 25 ft)
*
Stairway
Ladders
Ramps
Note: Sloping/benching for excavations deeper than 20 feet must be designed by a PE.
Competant Person Signature:
*
Date
*
/
Month
/
Day
Year
Date
What is your email?
*
example@example.com (A copy of the final permit will be sent here.)
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