GROUND DISTURBANCE PERMIT
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Operator
*
First Name
Last Name
Operator Email
*
example@example.com
Work Site Superintendent
*
Please Select
Brendan Hagle
Campbell Robertson
David Wyse
Jeff Iverson
Joe Ham
Kamil Franek
Kenny Vermette
Kit Hunter
Kurtis Jones
Mike Young
Shawn Hewitt
Work Site Superintendent Email
*
example@example.com
Work Site
*
24060 8th on 8th
24099 Canalta
24143 Charleston Phase 2
25025 BPL Alpine Apartments
25054 Mary's Popcorn
25077 Baymag Staff Training
25085 TOC Utility Facilities
25125 Outside Bike
25132 Mountain Animal Hospital
Procore Email
example@example.com
Company
*
Competent person trained in Ground Disturbance 2.0?
*
YES
NO
1. Have all utilities been marked and identified within proposed excavation area?
*
YES
NO
2. Have all affected parties been notified of excavation works?
*
YES
NO
3. Does the operator and workers have a copy of the locates and/or been shown where existing services are?
*
YES
NO
4. Has soil been classified prior to excavation taking place?
*
YES
NO
Confirm material type being excavated
*
5. Are protective systems required?
*
YES
NO
Confirm protective systems during the excavation process
*
6. Has the Excavator Operator and workers inspected the excavation prior to start of each work period?
*
YES
NO
7. Have all the work plans been discussed with all workers and the Site Superintendent?
*
YES
NO
8. Are all employees protected from cave-ins when entering and exiting the excavation?
*
YES
NO
9. Have hazardous objects around the excavation been removed or supported?
*
YES
NO
10. Is all spoil maintained at least 1 meter back from the edge of the excavation?
*
YES
NO
11. Are ladders used for access and egress?
*
YES
NO
11b. Are they placed as close as possible to the work area?
*
YES
NO
12. Are employees protected from loose materials or tools which could fall into the trench?
*
YES
NO
13. Are employees wearing the proper safety equipment?
*
YES
NO
14. Is the excavation free of standing or seeping water?
*
YES
NO
15. Is there evidence of cracking or sloughing of soil since the last inspection?
*
YES
NO
16. Is heavy equipment kept away from the edge of the excavation?
*
YES
NO
17. Are any changed conditions properly noted?
*
YES
NO
Additional comments on safety:
Excavator Operator Signature:
*
Back
Submit
Next
PERMIT APPROVED?
*
YES
NO
Comments
Site Superintendent Signature:
*
Site Superintendent Signature Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: