This section establishes the exact location, dimensions, and environmental context of the proposed excavation. All coordinates and measurements must be verified by a competent person before permit issuance. Inaccurate metadata invalidates this permit.
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
Stable Rock
Type A - Cohesive Soil
Type B - Cohesive/Granular Mix
Type C - Granular/Cohesionless
Type C-60 - Exceptionally Hazardous
Layered System - Mixed Types
Has a soil test (e.g., pocket penetrometer, shear vane) been conducted within the last 24 hours?
Select All Adjacent Structures or Conditions Within 6 Meters of Excavation Edge (Select all that apply)
Building Foundation
Roadway or Pavement
Railway Track
Bridge Abutment
Retaining Wall
Underground Parking
Heavy Equipment Operating Zone
Vibratory Compaction Area
None of the Above
Will traffic control measures be implemented to restrict vehicle loads near excavation?
Current Weather and Ground Conditions
Dry and Stable
Light Rain - Surface Moisture Only
Heavy Rain - Saturated Ground
Freezing Conditions - Frost Present
Thawing Conditions - Unstable
High Winds - Dust/Debris Hazard
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?
This section verifies that all underground utilities have been identified, located, and physically marked through multiple detection methods. A single detection method is insufficient for high-risk permits. All utility clearance distances must be confirmed before excavation begins.
Has a One-Call or equivalent utility notification service been contacted?
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
Utility Type | Utility Owner Company Name | Marked Color Code (APWA Standard) | Approximate Depth (Meters) | Horizontal Clearance from Excavation Edge (Meters) | Verified by Vacuum Excavation? | Conflict with Planned Excavation? | |
|---|---|---|---|---|---|---|---|
Electric High Voltage | PowerCo Grid | Red | 1.2 | 2.5 | Yes | ||
Gas Distribution Main | MetroGas Ltd | Yellow | 0.9 | 1.8 | Yes | Yes | |
Telecom Fiber Optic | DataFlow Comm | Orange | 0.6 | 3.2 | |||
Water Main | City Water Authority | Blue | 1.5 | 0.5 | Yes | Yes | |
Sanitary Sewer | City Waste Mgmt | Green | 2.1 | 1.2 | Yes | ||
Are there any unmarked or abandoned utilities suspected in the area?
Primary Geophysical Detection Method Used
Ground Penetrating Radar (GPR)
Electromagnetic Utility Locator
Frequency Locator (Active/Passive)
Magnetometer
Acoustic Pipe Locator
Multiple Methods Combined
Was Ground Penetrating Radar (GPR) scanning conducted?
Was electromagnetic detection used to verify metallic utilities?
Has vacuum excavation (potholing) been performed to physically verify utility depth and horizontal position?
Are all utilities cleared beyond the minimum approach distance (typically 0.5 meters for trenches, 3 meters for mechanical equipment)?
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?
This section ensures that appropriate protective systems are selected, installed correctly, and inspected daily by a competent person. The system must match the soil classification and excavation dimensions. Any deviation requires immediate engineering review.
Selected Protective System Type
Sloping/Benching (Open Cut)
Hydraulic Shoring with Vertical Sheeting
Pneumatic Shoring with Horizontal Walers
Trench Shield (Steel Box)
Aluminum Hydraulic Shoring
Engineered System - Custom Design
Combination System
Is the protective system design based on tabulated data from manufacturer or regulatory standards?
Has a registered professional engineer designed or approved this protective system?
Maximum Allowable Trench Depth for This Protective System (Meters)
Does this excavation exceed the maximum allowable depth for standard protective systems?
Has the protective system been inspected by a competent person before installation?
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?
Is the protective system installed exactly according to manufacturer specifications and engineering drawings?
Are spoil piles and equipment stored at least 0.6 meters from the excavation edge?
Are there any surcharge loads (equipment, materials) within the excavation influence zone?
Are safe access and egress points provided within 7.5 meters of lateral travel for all workers?
Number of Ladders, Ramps, or Stairways Installed
Is there visible evidence of water seepage or groundwater intrusion into the excavation?
Has the protective system been load-tested or proof-tested after installation?
Upload Photos of Installed Protective System from Multiple Angles Showing Full Configuration
This section ensures atmospheric hazards are identified, monitored, and controlled. Testing must be conducted at multiple depths and times. Continuous monitoring is required where oxygen deficiency or toxic gases are possible. Emergency rescue equipment must be on-site before entry.
Is this excavation deeper than 1.2 meters and could it contain a hazardous atmosphere?
Has the gas detection equipment been bump-tested and calibrated within the last 30 days?
Atmospheric Testing Log - Test Every 2 Hours and Before Each Shift Change
Test Date/Time | Oxygen % | Lower Explosive Limit % | H2S ppm | CO ppm | Tester Name | Atmosphere Safe for Entry? | |
|---|---|---|---|---|---|---|---|
7/14/2025, 6:30 AM | 20.8 | 0 | 0 | 0 | J. Martinez | Yes | |
7/14/2025, 8:30 AM | 20.7 | 0 | 0 | 0 | J. Martinez | Yes | |
Is ventilation equipment (blower, eductor) required to maintain safe atmosphere?
Is there standing water or evidence of water accumulation in the excavation?
Could adjacent industrial processes release gases or liquids into this excavation?
Is vibration monitoring required due to nearby operations or equipment?
Is noise monitoring required due to equipment or confined space acoustics?
Is emergency rescue equipment (tripod, winch, harness) positioned at the excavation?
Are workers equipped with personal gas monitors with audible/visual alarms?
Is there a communication system (radio, hardline) between entrant and attendant?
Has an emergency response plan been reviewed with all workers today?
Upload Photo of Gas Detection Equipment and Calibration Certificate
This final section requires joint authorization from both Site Superintendent and Safety Director. Both parties must physically inspect the site and verify all preceding sections. This permit is valid only for the date and time specified and must be reissued for any changes in conditions, personnel, or scope.
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
Worker Full Name | Company/Contractor | Role/Trade | Competent Person Designation | Safety Briefing Completed? | Acknowledges Stop Work Authority? | |
|---|---|---|---|---|---|---|
Carlos Mendez | ABC Excavation | Equipment Operator | No | Yes | Yes | |
Sarah Chen | ABC Excavation | Pipe Layer | No | Yes | Yes | |
David Okafor | Utility Locators Inc | Spotter | Yes | Yes | Yes | |
Maria Santos | Safety Watch Co | Atmospheric Tester | Yes | Yes | Yes | |
Has a pre-work safety briefing been conducted covering all hazards and controls?
Do all workers understand and acknowledge their stop work authority?
Select All Required Documentation Physically On-Site (Select all that apply)
This Signed Permit
Utility Marking Photos
Protective System Design Drawings
Gas Detector Calibration Certificates
Emergency Response Plan
Competent Person Credentials
Engineering Approvals
Traffic Control Plan
All of the Above
Are emergency contact numbers posted visibly at the excavation site?
Has a change in conditions been observed since initial inspection?
SITE SUPERINTENDENT DECLARATION: I have personally inspected this excavation site, reviewed all utility location verifications, confirmed protective system installation, witnessed atmospheric testing, and verified all safety controls are in place. I authorize work to proceed under the conditions specified. I understand that this permit is immediately void if any condition changes or if an incident occurs.
Site Superintendent Signature
Site Superintendent Printed Name
Superintendent License/Certification Number
Superintendent Sign-Off Date/Time
SAFETY DIRECTOR DECLARATION: I have independently verified all safety systems, reviewed atmospheric test logs, confirmed rescue equipment availability, ensured competent person qualifications, and validated emergency procedures. I concur with the Site Superintendent's authorization and confirm that all regulatory and company safety requirements have been met. I retain authority to suspend this permit at any 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)?
PERMIT STATUS: This permit is valid ONLY for the date, time, location, and conditions specified. Any deviation requires immediate permit suspension and re-authorization. All workers must cease work and evacuate if: unauthorized utility is encountered, protective system fails, atmospheric alarm sounds, water accumulation occurs, or competent person orders evacuation.
I acknowledge that I have read and understand all conditions and limitations of this permit