36C26118B0600-011.pdf

EXCAVATION (DIGGING/DRILLING) PERMIT

SECTION 1: To be completed prior to digging or drilling.

NOTE: Underground Service Alert (USA) North MUST be contacted at least 48 business hours prior to excavating deeper than 2 feet anywhere on the campus that public utilities could exist. USA North will gather relevant information and mark the general locations of gas, electric, cable and telephone lines, CALL 811 or 1-800-227-2600 Mon-Fri 0600-1900 hrs.

NOTE: When excavation operations approach the estimated location of underground installations, hand digging or excavation by other similar safe and acceptable means as excavation operations approach within 2 feet of identified underground utilities until it is certain that the installation will not be damaged by earth moving equipment. Exploratory bar or other detection equipment will be utilized as necessary to further identify the location of underground utilities.

A. Estimated start date and time:

From: _____/_____/_____ Time: AM PM To: _____/_____/_____ Time: AM PM

B. Specific location and nature of work:

C. Contractor’s Competent Person (printed name):

Evidence of qualifications submitted:

D. Is soil or concrete removal required? ___Yes ___No E. Are soil samples required? ___Yes ___No

I.H. Initials________ Safety Initials________

F. Coordination with appropriate local utility or USA North completed by:

Initials: Status: ___ All Clear ___Potential Conflict – Do Not Dig!

G. The following site drawings have been reviewed for proximity to digging (circle)

Electrical Gas/Oil/Steam Water Sewer/Drain Lines Data/Communication

The planned dig site was outlined/marked in white prior to coordinating utility location service on (Date):_____/_____/_____

Engineering review completed by:

H. The following sources apply and have been marked and locked/tagged prior to starting work (circle)

Electrical Gas/Oil/Steam Water Sewer/Drain Lines Data/Communication

I. Special instructions or equipment required (append additional requirements, if necessary):

NOTE: Lockout/tagout must be used with this permit when utility isolation is required.

NOTE: During dry months, dust dispersion should be controlled to the extent possible.

Maint. Sup. Initials________ Safety Officer Initials________ E&FMS Chief Initials_______

SECTION 2: To be completed prior to personnel entering excavations greater than 5 feet in depth or whenever conditions warrant if excavation depth is less than 5 feet.

A. Determination of OSHA classification of soil using pocket penetrometer (check)

� Stable Rock � Greater than 1.5 Tons/FT2 – Type A without condition to reduce to Type B � 0.5 Tons/FT2 to 1.5 Tons/FT2 – Type B � Less than 0.5 Tons/FT2 – Type C

B. Selected protective system (circle)

Sloping/Benching (Cannot be used for stable rock/Type A soil) Shoring Shielding

C. Verification of spoil piles being stored at least 2 feet from the edge of the excavation and safe access provided within 25 feet of the workers.

Engineering review completed by:

D. Air quality assessment for potentially toxic, explosive, or oxygen-deficient atmosphere.

� Excavation area deemed safe � Excavation area requires the following controls prior to personnel entry:

I.H. initials:________

E. For excavations greater than 20 feet, has the excavation protective system been designed and approved by a Professional Engineer. (circle)

___Yes ___No

Engineering review completed by:

Maint. Sup. Initials________ Safety Officer Initials________ E&FMS Chief Initials________