Authorization Permit for Excavation, Trenching & Digging Operations in Proximity to Underground Utility Infrastructure

Permit Number

Project Name & Contract Number

Exact Site Address or Mile Marker Location

Grid Reference Easting Coordinate (UTM or Local Grid System)

Grid Reference Northing Coordinate (UTM or Local Grid System)

GPS Latitude (Decimal Degrees)

GPS Longitude (Decimal Degrees)

Planned Excavation Depth (Meters)

Planned Excavation Length (Meters)

Planned Excavation Width (Meters)

Soil Classification Based on Competent Person Assessment

Describe the exceptional hazardous conditions requiring Type C-60 classification:

Describe each soil layer, thickness, and classification in this mixed system:

Has a soil test (e.g., pocket penetrometer, shear vane) been conducted within the last 24 hours?

Test Method Used and Unconfined Compressive Strength (kPa)

Select All Adjacent Structures or Conditions Within 6 Meters of Excavation Edge (Select all that apply)

Distance to Foundation (Meters)

Traffic Load Classification (Equivalent Single Axle Load)

Describe Equipment Type, Weight, and Operating Radius:

Will traffic control measures be implemented to restrict vehicle loads near excavation?

Describe Traffic Control Plan and Load Restrictions:

Current Weather and Ground Conditions

Has a geotechnical engineer approved work in these saturated conditions?

Engineer Name and Approval Reference Number

Has frost depth been verified to be below excavation depth?

Upload Site Sketch or Map Showing Excavation Boundaries, Utility Grid, North Arrow, and Scale

Has this location been previously excavated within the last 5 years?

Provide Previous Permit Numbers, Dates, and Any Incidents or Utility Strikes Recorded:

Has a One-Call or equivalent utility notification service been contacted?

One-Call Ticket Number

One-Call Ticket Expiration Date/Time

Have all utility owners responded and physically marked their underground facilities?

Utility Location Verification Matrix - Each Utility Must Be Documented

Are there any unmarked or abandoned utilities suspected in the area?

Describe Suspected Unmarked Utility, Evidence Basis, and Mitigation Plan:

Primary Geophysical Detection Method Used

List All Methods Used and Rationale for Combined Approach:

Was Ground Penetrating Radar (GPR) scanning conducted?

GPR Equipment Model, Frequency Range, Scan Density, and Key Findings:

Was electromagnetic detection used to verify metallic utilities?

EM Locator Model, Frequency Used, and Calibration Date:

Has vacuum excavation (potholing) been performed to physically verify utility depth and horizontal position?

Number of Vacuum Excavation Test Holes Completed

Are all utilities cleared beyond the minimum approach distance (typically 0.5 meters for trenches, 3 meters for mechanical equipment)?

Identify Utilities Within Clearance Zone and Describe Additional Protective Measures (e.g., hand digging, utility exposure, engineered protection):

Upload Photos of All Utility Markings Showing Color Codes, Reference Points, and Excavation Boundaries

Has a conflict matrix been prepared for utilities that cross or parallel the excavation?

Upload Utility Conflict Matrix and Mitigation Plan Document

Selected Protective System Type

Slope Ratio (Horizontal:Vertical) - e.g., 1.5:1

Engineer's Name and Design Approval Number

Describe Combination System Components and Integration Method:

Is the protective system design based on tabulated data from manufacturer or regulatory standards?

Tabulated Data Reference Number and Source Document

Provide Engineering Design Justification and Calculation Methodology:

Has a registered professional engineer designed or approved this protective system?

Engineer Registration Number and Approval Date

Maximum Allowable Trench Depth for This Protective System (Meters)

Does this excavation exceed the maximum allowable depth for standard protective systems?

Describe Engineered Controls for Deep Excavation (>6 meters) including Multiple Bench Levels or Stepped Systems:

Has the protective system been inspected by a competent person before installation?

Competent Person Name and Certification ID

I confirm that the competent person has training and experience in: soil analysis, protective system use, and regulatory requirements

Are all shoring components (panels, wales, struts, hydraulic cylinders) free from defects, damage, or excessive rust?

Describe Defective Components and Corrective Actions Taken:

Is the protective system installed exactly according to manufacturer specifications and engineering drawings?

Describe Any Deviations and Engineering Approval for Modifications:

Are spoil piles and equipment stored at least 0.6 meters from the excavation edge?

Actual Distance of Spoil Pile from Edge (Meters)

Are there any surcharge loads (equipment, materials) within the excavation influence zone?

Describe Surcharge Load, Weight, Distance from Edge, and Engineering Assessment:

Are safe access and egress points provided within 7.5 meters of lateral travel for all workers?

Describe Access/Egress Configuration and Justification for Extended Travel Distance:

Number of Ladders, Ramps, or Stairways Installed

Is there visible evidence of water seepage or groundwater intrusion into the excavation?

Describe Water Intrigation Rate, Pumping Capacity, and Dewatering Plan:

Has the protective system been load-tested or proof-tested after installation?

Test Load Applied (kN) and Test Date/Time

Upload Photos of Installed Protective System from Multiple Angles Showing Full Configuration

Is this excavation deeper than 1.2 meters and could it contain a hazardous atmosphere?

Potential Atmospheric Hazards (Select all that apply)

Will continuous atmospheric monitoring be used?

Has hot work permit been issued for this excavation?

Has the gas detection equipment been bump-tested and calibrated within the last 30 days?

Calibration Date and Next Due Date

Atmospheric Testing Log - Test Every 2 Hours and Before Each Shift Change

Is ventilation equipment (blower, eductor) required to maintain safe atmosphere?

Ventilation Equipment Type, CFM Rating, Placement Location, and Air Changes Per Hour:

Is there standing water or evidence of water accumulation in the excavation?

Water Depth, Source Assessment, and Dewatering Method (e.g., wellpoints, sump pumps):

Could adjacent industrial processes release gases or liquids into this excavation?

Describe Adjacent Process, Potential Contaminants, and Monitoring Strategy:

Is vibration monitoring required due to nearby operations or equipment?

Vibration Threshold Limits, Monitoring Equipment Location, and Real-Time Alert System:

Is noise monitoring required due to equipment or confined space acoustics?

Measured dBA Level at Worker Position

Is emergency rescue equipment (tripod, winch, harness) positioned at the excavation?

Rescue Equipment Capacity, Anchor Point Strength Verification, and Trained Rescue Personnel Name:

Are workers equipped with personal gas monitors with audible/visual alarms?

Number of Personal Monitors Deployed

Is there a communication system (radio, hardline) between entrant and attendant?

Describe Alternative Communication Method and Backup System:

Has an emergency response plan been reviewed with all workers today?

Emergency Assembly Point Location and Medical Facility Contact

Upload Photo of Gas Detection Equipment and Calibration Certificate

Permit Effective Date

Permit Start Time (Work Cannot Begin Before This Time)

Permit Expiration Time (Maximum 12-Hour Duration)

Total Number of Workers Authorized Under This Permit

Authorized Work Crew List - All Workers Must Be Briefed and Sign Below

Has a pre-work safety briefing been conducted covering all hazards and controls?

Briefing Topics Covered and Worker Questions/Concerns Raised:

Do all workers understand and acknowledge their stop work authority?

Select All Required Documentation Physically On-Site (Select all that apply)

Are emergency contact numbers posted visibly at the excavation site?

List Emergency Contacts: Utility Owners, Hospital, Fire, Poison Control, Site Management:

Has a change in conditions been observed since initial inspection?

Describe Changed Condition (weather, soil, utilities, atmosphere) and Engineering Re-Assessment:

Site Superintendent Signature

Site Superintendent Printed Name

Superintendent License/Certification Number

Superintendent Sign-Off Date/Time

Safety Director Signature

Safety Director Printed Name

Safety Director License/Certification Number

Safety Director Sign-Off Date/Time

Has this permit been reviewed and approved by a third-party safety auditor (if required by contract)?

Third-Party Auditor Signature (if applicable)

I acknowledge that I have read and understand all conditions and limitations of this permit