6630204 - Excavation/Ground Disturbance Permit

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Project Name
Project Number
EXCAVATION/GROUND DISTURBANCE PERMIT
Work Performed By*
Drawing*
Location of Excavation*
Reason for Excavation*
Start Date*

MonthDayYear
Date
Permit expires*

MonthDayYear
Date
Person Responsible for the Excavation*
Phone*
Format: (000) 000-0000.
WaterSewerGasPowerFire LinesProcess LinesOther
Comments Regarding Utilities in Excavation Area
% O2Explosion testingGas/Fume testingStanby personHand excavate at utility crossingGrounding of toolsBarricadesSpecial clothing
Other (Specify)
Comments
Craft Superintendent of Craft Excavating*

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Client Representative (if in an operating facility)

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Excavation Competent Person*

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HSE Representative (obtain this signature last)*

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COMPETENT PERSON CHECKLIST
Stable RockType AType BType C
YesNoN/A
YesNoN/A
YesNoN/A
YesNoN/A
YesNoN/A
Other obstructions/hazards:*
Slope will be*
Comments:*
Size of excavation:
Depth*
Width*
Length*
YesNoN/A
YesNoN/A
YesNoN/A
StairwaysLaddersRamps
Note: Sloping/benching for excavations deeper than 20 feet (6.1 m) must be designed by a PE.
Competent Person*

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Date*

MonthDayYear
Date
Should be Empty:

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