new_dig_permit_(7)-1.doc

PW / Base Civil Engineering Work Clearance Request Request Number

LKE-

1. Clearance is requested to proceed with work at: __________________________________________ on work order no. __________, contract no._____________________, involving excavation per attached sketch or drawing. The area has has not been clearly marked with white paint.

2. Type of Facility Work Involved

____ A. Pavement ___ D. Fire Protection / Detection Systems ____ G. Aircraft or Vehicle Traffic Flow ____ B. Drainage Systems ___ E. Utility ( underground ) ___ H. Security ____ C. Railroad Tracks ___ F. Comm. ( underground ) ____ I Other

3. Date Clearance Requested 4. Date Submitted 5. Name of Requestor

6. Signature of Requesting Official 7. Contact Telephone 8. Company or Organization

9. Commercial Utilities ( ONE CALL) Comm. 1-800-272-1000 Interstate ( 609) 267-9100

___ Telephone ____ Natural Gas ____ Electric ( Street Lights ) Confirmation Number ___________________________ It is the requestors responsibility to contact One Call before submitting request

Organization Name of person performing mark out Reviewers name Initials

A. Electric

Chris Belinsky B Distribution

( 732 ) 323-2255 B-199

A S B. Water / Sewer E Distribution

( 732 ) 323-2562 B-272 C. Fire

C Protection

( 732) 323-2562 B-272

E S D Fuel LIne

Distribution

E. Steam

Distribution

F. Environmental Check for Well points, if present they must be marked out ( 732 ) 323-7544 B-5 G. Housing Area

( 732 ) 323-7225 B-483

G. Fiber Optic

( 732 ) 323-1643 B-1

H. Communications` ( 732 ) 323-2008 B-1

I. Safety ( 732) 323-2525 B-5 J. Security / Police

( 732 ) 323-2500 B-8

K. Base Operations Only applicable if work is within Airfield Area ( 732 ) 323-4940 B-307

Permit Valid for 30 Days from Date of Approval

Printed Name & Signature of Approver Date