Atch__17_-_BLANK_SAMPLE_Dig_Permit_Form_v3.0.pdf

RENEWAL? _____NO_____YES__________DATE

78th CIVIL ENGINEER GROUP DIGGING PERMIT

Purpose: A digging permit is required for all work (contract or in-house) that may disrupt aircraft, vehicular, or personnel traffic flow, base utility services, protection provided by fire and intrusion alarm systems or routine activities of the installation. This form is used to coordinate the required work with key base activities and to identify potentially hazardous work conditions in an attempt to prevent accidental damage to base utilities and to ensure the proper restoration of the excavated site.

Damage: All Utilities must be located by hand when digging within 3 feet of any utility. Digging near marked cables shall be accomplished as spelled out in the contract specifications and drawings. Permittee also agrees not to use “plowing” implements to trench and install utilities. A sandblade is mandatory. All cost to restore service to base utilities resulting from damage will be billed to permittee. In case of emergency on base, call 222-2900 from personal cell phones and 911 from base land line phones.

GIS Notification: Promptly notify the Geobase office should digging uncover any undocumented utility lines or result in the relocation of known utility lines. It will be mutually beneficial to notify the Geobase office when the utilities are visible and or uncovered so that the utility can be documented and or captured with high-accuracy GPS. With that said, upon notification it will be incumbent upon the Geobase office to accommodate the site manager and project schedule in such a way as not to cause unnecessary hindrance.

Utility Outages: Utility outage forms can be obtained up in the CE conference room every Wednesday from 1000 to 1030 hrs. Your government representative must be present.

I. Permit Section:

a. Clearance is requested to proceed with work at: _________________________________________

b. Work order #:__________________________________________________________________

c. Project #:_____________________________________________________________________

d. Contract # :____________________________________________________________________

e. Utilities Protection Center ticket (UPC) #:_______________________________________________

f. Specific Description & scope of work:________________________________________________________________

_Repair _ Communication _Irrigation _Steam _A&E

_Replace _ Compressed Air _Fuels _Industrial Waste _Water

_Relocate _ Electric _Sanitary Sewer _Environmental

_New Installation _ Natural Gas _ Storm Sewer _Landscaping

g. Your organization or Company name:___________________________________________________

h. Print name and phone number of on-site Foreman:__________________________________________

i. Print name and phone number of Gov’t Representative:_______________________________________

j. I certify that the subcontractor(s) have been or will be briefed on the method and limits of excavation and will be provided a copy of this form to retain while working on Robins AFB. All subcontractors on the work site will comply with precautionary measures

• I agree to comply with the site restoration plan.

• I certify that I have personally visited the site covered under this permit and that the site will be properly restored as found prior to excavation.

• I further certify that it is my responsibility to ensure the area is kept marked at all times.

Signature: _____________________________________________________________________

Date: _________________________________________________________________________

II. Road Cuts:

Approved by: ________________________________________________________________

Date: _________________________________________________________________________

DO NOT WRITE BELOW THIS LINE

*Approved by: _______________________________________________________________________________________________

Date: ________________________________________________________________________________________________

Permit Expiration: ______________________________________________________________________________________

Assigned Date & Time:

Notes: ______________________________________________________________________________________________________

* This Dig Permit is NOT valid without above signature completed.

Contact Company/Shop Location Phone Cleared to Dig? Initials Date

Dig Permit Manager Zach Porter Geobase Office Bldg. 1555 733-3599

Communication Lines Robert Warren Comm Squadron Hwy 214 396-4028

Electrical Robby Lane Exterior Electric Bldg. 1555 538-9324

Environmental Impact Gary Cox Environmental Bldg. 359 327-9269

GIS Utility Drwgs & GPS Zach Porter Geobase Office Bldg. 1555 327-2920

Cox Cable www.gaupc.com Cox Communications Hwy 247 1-800- 282-7411

Utilities Protection Center www.gaupc.com Duluth, Georgia

1-800- 282-7411

Pvmts/Storm Drainage Matt Woods Horizontal Bldg. 1555 327-8954

POL Systems Arnold Hubbard Fuels Distribution Bldg. 2086 327-3817

Runway & Ramp access Airfield Mgr. Airfield Management Bldg. 111 472-6570

Steam & Chilled Water Mike Grover Industrial Mechanical Bldg. 1555 327-8959

Water, Sewer, Natl Gas, Ind Waste Irrigation Randy Daniels Plumbing (CEUU) Bldg. 288 327-8964

Watson Cable Robbie Watson Watson Cable 1127 Leverett 922-9440

Unit Safety Rep Thomas McDaniel Safety Bldg 1555 497-8929