Provide precise geospatial data and excavation parameters. Accurate positioning is critical for utility avoidance and emergency response. All coordinate systems must be clearly defined and consistently applied.
Project Identification Number
Site Manager Name
Permit Validity Start Date/Time
Permit Validity End Date/Time
GPS Latitude (Decimal Degrees)
GPS Longitude (Decimal Degrees)
Grid Reference System
Grid Northing/Y-Coordinate
Grid Easting/X-Coordinate
Planned Maximum Excavation Depth (meters)
Planned Minimum Depth of Utilities (meters)
Excavation Operation Type
Heavy Mechanical Excavation
Pile-Driving
Both Operations
Other Specialized Equipment
Detailed Description of Excavation Purpose and Scope
Excavation Equipment Specifications
Equipment Type | Model/Specification | Operating Weight (tonnes) | Maximum Reach/Depth (meters) | Impact Energy (kJ) if applicable | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Hydraulic Excavator | CAT 336 | 36 | 6.5 | 0 | |
2 | Vibratory Pile Driver | ICE 416L | 12.5 | 8 | 416 | |
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Is the planned excavation within 5 meters of any known high-voltage or gas utility corridor?
Measured minimum distance to nearest critical utility (meters)
Confirm that all utility locating surveys have verified a minimum 5-meter clearance buffer zone.
Planned Horizontal Clearance Distance from Marked Utility (meters)
Document all sub-surface detection survey results. Incomplete or inconclusive surveys must be resolved before authorization. Attach all raw data and marked site photographs.
GPR Survey Completion Date/Time
Electromagnetic Locating Survey Completion Date/Time
Survey Equipment and Technician Details
Survey Type | Equipment Model | Frequency/Configuration | Last Calibration Date | Certified Technician ID | Data Quality Score (1-5) | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | GPR | Sensors & Software PulseEKKO Pro | 250 MHz | 6/1/2025 | TECH-GRP-784 | ||
2 | EM Locator | Radiodetection RD8200 | Active/Passive | 6/15/2025 | TECH-EM-452 | ||
3 | |||||||
4 | |||||||
5 | |||||||
6 | |||||||
7 | |||||||
8 | |||||||
9 | |||||||
10 |
Was complete grid coverage achieved with both GPR and EM methods?
Explain coverage gaps and compensatory measures taken
Survey Methodology and Grid Spacing Details
Detected Sub-Surface Utilities and Anomalies
Utility/Anomaly ID | Detection Method | Estimated Depth (meters) | Horizontal Position Offset (meters) | Confidence Level | Surface Marking Method | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | UTIL-001 | Both GPR & EM | 1.2 | 0.5 | High - Confirmed | Paint + Flags | |
2 | UTIL-002 | EM Only | 0.8 | 2.1 | Medium - Probable | Paint Only | |
3 | ANOM-003 | GPR Only | 2.5 | 1.8 | Low - Uncertain | Caution Tape | |
4 | |||||||
5 | |||||||
6 | |||||||
7 | |||||||
8 | |||||||
9 | |||||||
10 |
Were any utility depth or position conflicts identified between GPR and EM results?
Detail conflict resolution methodology and final determined position
Did surveys detect any unknown or unrecorded utilities?
Describe unknown utility characteristics and additional verification steps taken
Technical Interpretation Notes and Survey Limitations
Upload Raw GPR Data Files (e.g., .dzx, .sgy format)
Upload Site Photographs Showing Utility Markings
Overall Survey Reliability Rating (1 = Unreliable, 10 = Highly Reliable)
Obtain and verify official utility clearance before proceeding. Direct confirmation from utility owners is mandatory for high-risk corridors. Document all reference numbers and conditions.
Municipal One-Call Service Reference Number
One-Call Ticket Issuance Date/Time
One-Call Ticket Expiration Date/Time
Individual Utility Owner Clearance Verification
Utility Type | Owner/Operator Organization | Contact Person Name | Contact Phone | Clearance Reference Number | Clearance Status | Conditions or Restrictions | ||
|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | ||
1 | High-Voltage Electric | PowerGrid Corp | John Smith | +1-555-0101 | PWR-CL-78452 | Conditional Clearance | Maintain 3m horizontal clearance, monitor for vibrations | |
2 | Natural Gas | GasNet Utility | Sarah Chen | +1-555-0102 | GAS-CL-45218 | Full Clearance Granted | None | |
3 | Telecom/Fiber | FiberComm Inc | Mike Johnson | +1-555-0103 | TEL-CL-96532 | Requires On-Site Rep | Owner rep must be present during pile-driving | |
4 | ||||||||
5 | ||||||||
6 | ||||||||
7 | ||||||||
8 | ||||||||
9 | ||||||||
10 |
Have all utility owners provided positive clearance or agreed terms?
Identify which utilities have not cleared and explain work stoppage plan
Primary Clearance Verification Method
Municipal One-Call 811 Service
Direct Owner Contact
Third-Party Certified Locator
Combination of Methods
On-Site Utility Representative
Applicable Clearance Limitations (select all that apply)
Depth Restriction
Time-of-Day Restriction
Continuous Monitoring Required
Vibration Monitoring Required
Utility Representative On-Site
Hand Digging Zone
Other Special Condition
Is a utility owner representative required to be on-site during operations?
Representative Name and Expected Arrival Time
Summary of All Special Conditions and Restrictions
Upload All Utility Clearance Documentation and Correspondence
A strike on high-voltage or gas utilities can be catastrophic. This section must be completed with absolute precision. All personnel must be briefed on these procedures before work begins.
Emergency Response Contact Directory
Emergency Role | Contact Name | Primary Phone | Alternative Phone | Expected Response Time | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Site Manager | Robert Martinez | +1-555-0201 | +1-555-0202 | Immediate | |
2 | Lead Safety Engineer | Jennifer Park | +1-555-0203 | +1-555-0204 | Within 15 minutes | |
3 | Utility Emergency (Electric) | PowerGrid Emergency | +1-555-URGENT | 112 | Within 30 minutes | |
4 | Utility Emergency (Gas) | GasNet Emergency | +1-555-GAS-911 | 112 | Within 20 minutes | |
5 | Medical Emergency | On-Site Medic | +1-555-0205 | 911 | Immediate | |
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Have all emergency shut-off valve and isolation point locations been identified and physically verified?
Describe shut-off locations, access routes, and any access obstacles
STOP WORK - Cannot proceed until all isolation points are identified and accessible.
Step-by-Step Emergency Shut-Off Procedure
Strike Severity Level Classification
Level 1 - Minor Contact (No Damage)
Level 2 - Damage Without Leak/Breach
Level 3 - Gas Leak or Electrical Arc
Level 4 - Catastrophic Failure
Document inspection and monitoring plan for Level 1 event
Document isolation and repair coordination plan for Level 2 event
Document immediate evacuation and emergency service notification for Level 3 event
Document mass evacuation and incident command transfer for Level 4 event
Emergency Response Equipment Status
Equipment Type | Equipment Location | Quantity Available | Last Inspection Date | Operational Status | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Combustible Gas Detector | Tool Crib - Unit 5 | 2 | 6/25/2025 | Yes | |
2 | Non-Contact Voltage Detector | Safety Trailer | 3 | 6/27/2025 | Yes | |
3 | CO2 Fire Extinguisher | Equipment Staging | 4 | 6/20/2025 | Yes | |
4 | Trauma First Aid Kit | Site Office | 2 | 6/28/2025 | Yes | |
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Is a site-wide evacuation plan established and communicated?
Describe evacuation routes, assembly points, headcount procedures, and communication methods
STOP WORK - Evacuation plan is mandatory before any excavation begins.
Are nearby structures, buildings, or public areas at risk from a potential utility strike?
At-Risk Structures and Protection Measures
Structure Name/ID | Distance from Excavation (meters) | Risk Type | Protection Measures Implemented | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Office Building Wing B | 15.5 | Gas Explosion | Continuous gas monitoring, blast barrier installed | |
2 | Public Sidewalk | 8.2 | Occupant Safety | Pedestrian detour, safety observer posted | |
3 | |||||
4 | |||||
5 | |||||
6 | |||||
7 | |||||
8 | |||||
9 | |||||
10 |
Immediate Actions to be Taken by Equipment Operator Upon Suspected Strike
Confidence Level in Emergency Preparedness (1 star = Low, 5 stars = High)
Upload Comprehensive Emergency Response Plan Document
This joint sign-off confirms that all safety protocols have been reviewed, all hazards identified, and all necessary precautions are in place. Both signatories share equal responsibility for authorizing this high-risk operation.
Have all four preceding sections been thoroughly reviewed and verified as complete and accurate?
STOP WORK - All sections must be fully completed and verified before sign-off.
Additional Observations, Concerns, or Special Precautions
Has a pre-excavation safety briefing been conducted with all personnel and subcontractors?
List briefing attendees and summarize key safety points communicated
STOP WORK - Mandatory safety briefing must be completed before authorization.
Joint Authorization Sign-Off
Authorized Role | Name (Printed) | Employee/Professional ID | Signature | Date/Time of Sign-Off | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Site Superintendent | |||||
2 | Lead Safety Engineer | |||||
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
I acknowledge that this clearance permit is valid ONLY for the specific date, time, location, and conditions detailed in this form.
I understand that any deviation from the approved plan, including changes in equipment, depth, location, or timing, requires a new clearance permit.
I confirm that all emergency contact numbers have been tested and are operational at the time of sign-off.
Overall Site Risk Assessment for This Operation (1 = Minimal Risk, 10 = Extreme Risk)
Final Joint Authorization Signature (Both parties must be present)
This permit becomes effective only upon completion of both signatures above. Work must not commence before authorization. Keep this permit readily accessible at the work site at all times.
To configure an element, select it on the form.