Atch 19-APPENDIX 17 AF Form 103 - Dig Permit.pdf

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DATE PREPARED

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

1. Clearance is requested to proceed with work at on Work Order No.

, Contract No.

, involving excavation or utility disturbance per attached sketch. This area has has not been staked or clearly marked.

2. TYPE OF FACILITY/WORK INVOLVED

G. AIRCRAFT OR VEHICULAR TRAFFIC FLOW

A. PAVEMENTS

D. FIRE DETECTION & PROTECTION SYSTEMS

H. SECURITY

B. DRAINAGE SYSTEMS

E. UTILITY

OVERHEAD

UNDERGROUND

I. OTHER

C. RAILROAD TRACKS

F. COMM

OVERHEAD

UNDERGROUND

4. DATE OF CLEARANCE

3. DATE CLEARANCE REQUIRED

5. SIGNATURE OF REQUESTING OFFICIAL

6. TELEPHONE NO.

7. ORGANIZATION

REMARKS

(Use Reverse for additional comments)

REVIEWER'S NAME AND INITIALS

ORGANIZATION

8.

A. ELECTRICAL DISTRIBUTION

B A S

B. STEAM DISTRIBUTION

E

C. WATER DISTRIBUTION

C I

D. POL DISTRIBUTION

V I L

E. SEWER DISTRIBUTION

E N

F. ENVIRONMENTAL

G I

G. PAVEMENTS/ GROUNDS

N E E

H. FIRE PROTECTION

R I

I. ZONE

N G J. OTHER (Specify)

9. SECURITY POLICE

10. SAFETY

11. COMMUNICATIONS

12. BASE OPERATIONS

13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

TELEPHONE

GAS

ELECTRIC

15. OTHER (Specify)

APPROVED

DISAPPROVED

16. REQUESTED CLEARANCE

17. TYPED NAME AND SIGNATURE OF APPROVING OFFICER (Chief of Operations Flight or Chief of Engineering Flight) 17a. DATE SIGNED

PREVIOUS EDITIONS ARE OBSOLETE.

AF IMT 103, 19940801, V3

Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign

INSTRUCTIONS

The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular traffic flow, base utility services, protection provided by fire and intrusion alarm system, or routine activities of the installation. This form is used to coordinate the required work with key base activities and keep customer inconvenience to a minimum. It is also used to identify potentially hazardous work conditions in an attempt to prevent accidents. The work clearance request is processed just prior to the start of work. If delays are encountered and the conditions at the job site change (or may have changed) this work clearance request must be reprocessed.

18. REMARKS. (This section must describe specific precautionary measure to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment, should be included.)

AF IMT 103, 19940801, V3

(REVERSE)

8.2.1.3158.1.475346.466429

811. USA NORTH REQUIRES TWO FULL WORKING

DAYS NOTICE BEFORE YOU DIG. USA NORTH

TICKET #

*** REQUESTOR IS RESPONSIBLE FOR MAINTAINING MARKINGS ***

*DIG REQUEST NEEDS TO BE SUBMITTED 30 DAYS IN ADVANCE.*

1. WHAT IS THE PURPOSE OF THE DIGGING?

2. IF THIS WORK IS BEING COMPLETED BY CONTRACT PROVIDE NAME OF NAFB POINT OF CONTACT

3. INCLUDE MAP WITH DIMENSIONS AND A PLAIN VIEW REFERENCE POINTS. This map needs to include access roads, storage of equipment, and stockpiles and be consistent with the dimensions provided in question 5.

4 WHAT IS THE SPECIFIC ADDRESS AND LOCATION OF AREA BEING DUG? If more than one location, provide addresses of all the locations.

5. WHAT IS THE TOTAL AREA IN ACRES THAT IS GOING TO BE DISTURBED? Please include access roads, storage of equipment, and stockpiles in the total. _________

If above 0.25 acres, did you include a copy of your dust permit? Yes or No If above 1 acre, did you include your SWPPP? Yes or No

6. WHAT IS THE SPECIFIC LOCATION OF DIGGING STARTING POINT?

7. WHAT IS THE SPECIFIC LOCATION OF DIGGING ENDING POINT?

8. IF TRENCHING, PROVIDE THE FOLLOWING?

LINEAR FEET: ____________ DEPTH: ____________ WIDTH: ____________

If trenching is over 100 ft, did you include a copy of your dust permit? Yes or No

9. WHAT IS THE PROJECTED DATE DIGGING WILL START/END DATES?

START DATE: ____________ END DATE: ____________

10. WILL THIS DIGGING PERMIT REQUIRE A UTILITY OUTAGE ( ELECT, GAS, WATER)?

11. WILL YOU BE RESTRICTING OR CLOSING ROADS/PARKING LOTS TO FACILITATE THE WORK?

IF UNSURE ON HOW TO PROCESS THIS APPLICATION, PLEASE CONTACT AIR QUALITY AT (702) 652-2882.

*Please note any changes to your project need to be reevaluated for the appropriate permits through a new dig application.

**A copy of the Dust Permit must be submitted to Nellis.Air.Quality@us.af.mil once approved by the Clark County. 01Nov23