Attachment 04 DSCC Excavation Permit.pdf

DEFENSE SUPPLY CENTER COLUMBUS EXCAVATION PERMIT

PERMIT NUMBER

In case of an emergency, dial 911 from a DSCC phone or call the DSCC Fire Department at (614) 692-2111.

PROJECT NAME DATE

PROJECT START DATE PROJECT END DATE DURATION

PRIME CONTRACTOR SUB-CONTRACTOR / EXCAVATION CONTRACTOR

CONTRACTOR REPRESENTATIVE CONTRACTOR REPRESENTATIVE PHONE NO.

DSCC FACILITIES REPRESENTATIVE DSCC FACILITIES REPRESENTATIVE PHONE NO.

DESCRIPTION OF WORK AND LOCATION

Excavation by Contractor include applicable drawings.

Excavation by Government

Excavation / Trench Depth: Less than 5 ft. Greater than 5 ft. Greater than 20 ft.

Note: If excavation depth is greater than 5 ft., a soil analysis will be required to determine the appropriate Protective System that will be utilized. A Competent Person shall be on site during trenching and/or excavating activities.

SOIL ANALYSIS CONTRACTOR COMPETENT PERSON SOIL ANALYSIS CONTRACTOR PHONE NO.

SOIL ANALYSIS METHOD UTILIZED NAME OF PROFESSIONAL ENGINEER (if excavation is greater than 20 ft.)

SOIL ANALYSIS RESULTS PROVIDED TO FACILITIES: Yes No

CONTRACTOR REVIEWED UTILITY DRAWINGS: Yes No

UNDERGROUND UTILITIES IDENTIFIED: Yes No If no, provide explanation:

INSTRUMENTS UTILIZED TO IDENTIFY UNDERGROUND UTILITIES: Passive or Active Electromagnetic RF Detector

Ground Penetrating Radar

Other (provide type):

UTILITIES CHECKED BELOW WERE IDENTIFIED, AND MARKED ACCORDINGLY AT THE WORK LOCATION

Electrical Water Sewer Compressed Gas Communications* Stormwater

IS PROTECTIVESHORING SYSTEM REQUIRED: Yes No

Shoring Shielding Benching Sloping Not Applicable

REVIEWED BY CONCURRENCES

PRINT SIGN DATE

CONTRACTOR (Required) (Company Name)

SUBMITTED BY

DSCC FACILITIES REPRESENTATIVE

PROFESSIONAL ENGINEER DATE

(if excavation is greater than 20ft.)

COMPETENT PERSON DATE

NOTES: PERMIT SHALL BE KEPT AT THE WORK LOCATION AT ALL TIMES

* If Communications utilities are present Defense Information Systems Agency (DISA) may require 30 Days Advanced Notice prior to excavation