DIG PERMIT 04192023.pdf

4.EMERGENCY URGENT ROUTINE

Yes No

- The Project Manager or Responsible Party shall field mark the alignment of all intended excavations with flags or non-permanent white paint.

-The Project Manager and/or Contractor must maintain the Red Stakes markings.

- The project manager or responsible party will notify the contractor when the permit is complete and excavation can begin.

RESPONSIBILITY STATEMENT: The responsible individual's signature (Item # 9) indicates that they understand their responsibilities regarding maps and utility markings. If the responsible individual is a contractor, their signature denotes acceptance of all financial and other responsibilities as it relates to any damage to utilities and personnel as identified by the Red Stake office. It is further understood that in the event of a line strike, however minor, work will immediately stop, the site will be cleared of personnel, and

Customer Service will be immediately notified. (777-1856)

*HYDRA VAC or HAND DIGGING IS REQUIRED WITHIN A MINIMUM OF 3 FEET OF ALL UTILITIES!!

**PLEASE REMOVE ALL MARKINGS AFTER WORK IS COMPLETE.

GENERAL

INFORMATION ENTITY PHONE DATE

BASE CIVIL ENGINEERING EXCAVATION PERMIT

6. WORK LOCATION OR AREA:

PRINT NAME SIGN NAME

3. JO# / WO#/ CONTRACT PROJECT:2. PROJECT MANAGER OR CE REQUESTER NAME AND PHONE:

***This permit is required to be on hand, on site, during ANY excavation.*** All utility markings are valid for 30 Days

PERMIT VALID UNTIL:

PERMIT NUMBER #:

IN CASE OF EMERGENCY PLEASE CALL 777-1856

7. WORK DESCRIPTION: 8: COMPANY NAME & PHONE:

9. COMPANY REPRESENTATIVE:

1. DATE SUBMITTED

(ALLOW 14 DAYS)

5. SITE VISIT REQUESTED:

SIGNATURE OF

LOCATER

Storm drain, low voltage, gas, Industrial Waste, Environmental

801-695-9785

RED STAKE 777-0540

All excavation work within a 15 ft radius of high pressure natural gas distribution lines requires Questar Gas technicians to be on-site during the dig, this will be coordinated through Blue Stake.

BLUE STAKE

Blue Stakes Permit #___________________________

AMERICAN WATER

SERVICE

CITY LIGHT & POWER

GROUNDS QA

Water & Sewer

High Voltage

Ground Sprinklers/Irrigation

801-660-2255

775-4133

COMM 801-586-8903 For all COMM

Blue Stake permit needed?

CALL 3 DAYS AHEAD

75 CEG/CEOER FORM 12, 19 April 2022

YES NO

RED GREEN

ORANGE BLUE

YELLOW WHITE

PURPLE PINK

Were all records properly filed?

12. ADDITIONAL REMARKS (PRECAUTIONARY MEASURES TO BE TAKEN)

Certifying Technician's Checklist:

Post approval:

Was a periodic inspection made? ________ Dates:_________________

Were markings accurate? _________

Was labor charged?

75 CEG/CEOER FORM 12, 19 April 2022

UTILITY COLOR CODES

ELECTRIC POWER LINES, POWERED CONDUITS STORM & SANITARYSEWERS, DRAIN LINES

Was the CE requestor/Alternate contacted upon completion of request.

11. RED STAKE CHECKLIST:

Is the information for sections 1-10/12 properly filled out by an appropriate government representative?

Prior to approval:

Make appropriate entries to Red Stake log and file copies.

RECLAIMED WATER & IRRIGAION TEMPORARY SURVEY MARKER

10. All Subsurface utilities installed shall use tracer wire as specified in the Hill Air Force Base Design Standard. Utility shall be defined as, but not limited to: electric systems; storm, sanitary and subsurface drainage systems including French drains, rain gutter collection and distribution systems, and other water collection systems; potable and non-potable water systems; natural gas systems; industrial waste systems;

fuel systems; communication systems; street lighting systems; heating and cooling systems; airfield associated systems; environmental systems; other objects designed for future use such as burried conduits and pipes; and other comparable items, objects or systems. The determination and definition of a utility requiring tracer wire shall be at the sole discretion of the United States Air Force.

COMM LINES, CABLES, & UNKNOWS POTABLE WATERM, IRRIGATION & SLURRY LINES

GAS, OIL, PETROL & OTHER GASEOUS MATERIALS DIGGING SITE BOUNDARIES TRENCH LINES

Has the site been properly marked to indicate area to be excavated?

Has a visual inspection of the area requiring locate been performed. Has the obvious been identified?

Was the area properly scanned utilizing all available equipment and resources? Locator/Ground Radar etc..

Were utility color codes properly used when identifying utilities?

DATE: __________________________ Individual receiving information:_________________________________________________________________

IN CASE OF EMERGENCY PLEASE CALL 777-1856

Has appropriate research been accomplished prior to site investigation? GIS map and G Tabs etc..

13. Extensions :

Permit Extension Valid Until

Redstake Authorized Signature ( P e r m i t e x t e n s i o n o n l y v a l i d w i t h a u t h o r i z e d s i g n a t u r e . )

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