SCMV Ground Disturbance Permit

  • GROUND DISTURBANCE PERMIT

  • Date*
     - -
  • Site Superintendent*
  • Work Site*
  • Company*

  • Engineering Controls

  • 1. Have all utilities been marked and identified within proposed excavation area?*
  • 2. Does the operator and workers have a copy of the locates and/or been shown where existing services are?*
  • 3. Has soil been classified prior to excavation taking place?*
  • 4. Are protective systems required?*
  • 5. Are all employees protected from cave-ins when entering and exiting the excavation?*
  • 6. Have hazardous objects around the excavation been removed or supported?*
  • 7. Is all spoil maintained at least 1 meter back from the edge of the excavation?*
  • 8. Are ladders used for access and egress?*
  • 8b. Are they placed as close as possible to the work area?*
  • 9. Are employees protected from loose materials or tools which could fall into the trench?*
  • 10. Is the excavation free of standing or seeping water?*
  • 11. Is there evidence of cracking or sloughing of soil since the last inspection?*
  • 12. Is heavy equipment kept away from the edge of the excavation?*

  • Administrative Controls

  • 13.Competent person trained in Ground Disturbance 201?*
  • 14. Has the Excavator Operator and workers inspected the excavation prior to start of each work period?*
  • 15. Have all affected parties been notified of excavation works?*
  • 16. Have all the work plans been discussed with all workers and the Site Superintendent?*

  • PPE Controls

  • 17. Are employees wearing the proper safety equipment?*
  • 18. Are any changed conditions properly noted?*
  • PERMIT APPROVED?*
  • Site Superintendent Signature Date*
     - -
  • Should be Empty: