11.5.6_FC_Form_86-E_Dig_Permit_Request.pdf
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11.5.6 FC Form 86-E Dig Permit Request
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FC FORM 86-E, JAN 2015
PREVIOUS EDITIONS ARE OBSOLETE
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FACILITIES ENGINEERING DIG PERMIT REQUEST
(DPW is the proponent; the approving authority is FC Reg 420-20)
INVOLVING EXCAVATION, UTILITY, OR OTHER DISTURBANCES PER ATTACHED SKETCH.
2. TYPE OF FACILITY WORK INVOLVED - EXPLAN THE EXACT LOCATION AND PROPOSED WORK:
2. TYPE OF FACILITY WORK INVOLVED - EXPLAN THE EXACT LOCATION AND PROPOSED WORK:
2. TYPE OF FACILITY WORK INVOLVED - EXPLAN THE EXACT LOCATION AND PROPOSED WORK:
3. INSTRUCTIONS: This work clearance request is used for any work (contract or in-house) that may disrupt vehicular, rail, or air traffic flow, 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 installation 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 must be reprocessed. If you have any questions, please call the Dig Permit Coordinator at 526-3089 or the Utility Locator at 524-0892.
ORGANIZATION
ORGANIZATION
ORGANIZATION
10. COMMUNICATIONS (HELP DESK) 526-5232
10. COMMUNICATIONS (HELP DESK) 526-5232
10. COMMUNICATIONS (HELP DESK) 526-5232
TICKET NUMBER
TICKET NUMBER
TICKET NUMBER
REVIEWER'S NAME & DATE
REVIEWER'S NAME & DATE
REVIEWER'S NAME & DATE
8. UNCC 1-800-922-1987
8. UNCC 1-800-922-1987
8. UNCC 1-800-922-1987
9. CITY OF FOUNTAIN WATER 382-5604
9. CITY OF FOUNTAIN WATER 382-5604
9. CITY OF FOUNTAIN WATER 382-5604
11. ENVIRONMENTAL COMPLIANCE 526-1682
11. ENVIRONMENTAL COMPLIANCE 526-1682
11. ENVIRONMENTAL COMPLIANCE 526-1682
12. BARRACK PHONE (SPRINT) 579-1000
12. BARRACK PHONE (SPRINT) 579-1000
12. BARRACK PHONE (SPRINT) 579-1000
13. GOVERNMENT UTILITIES
13. GOVERNMENT UTILITIES
13. GOVERNMENT UTILITIES
REMARKS AND INITIALS
TICKET NUMBER
TICKET NUMBER
a. ELECTRICAL DISTRIBUTION
a. ELECTRICAL DISTRIBUTION
a. ELECTRICAL DISTRIBUTION
REVIEWER'S NAME & DATE
REVIEWER'S NAME & DATE
REVIEWER'S NAME & DATE
b. GAS DISTRIBUTION
b. GAS DISTRIBUTION
b. GAS DISTRIBUTION
c. CATHODIC PROTECTION
c. CATHODIC PROTECTION
c. CATHODIC PROTECTION
d. WATER DISTRIBUTION
d. WATER DISTRIBUTION
d. WATER DISTRIBUTION
e. IRRIGATION SYSTEMS
e. IRRIGATION SYSTEMS
e. IRRIGATION SYSTEMS
f. SEWER LINES
f. SEWER LINES
f. SEWER LINES
g. STORM DRAIN SYSTEM
g. STORM DRAIN SYSTEM
g. STORM DRAIN SYSTEM
h. STEAM DISTRIBUTION
h. STEAM DISTRIBUTION
h. STEAM DISTRIBUTION
i. CHILLED WATER
i. CHILLED WATER
i. CHILLED WATER
j. COMPUTER/TRAFFIC
j. COMPUTER/TRAFFIC
j. COMPUTER/TRAFFIC
k. OTHER
k. OTHER
k. OTHER
14. ROAD CLOSURE; IF NEEDED, PLEASE COMPLETE FC FORM 420-E (FORT CARSON UTILITY OUTAGE/CONNECTION REQUEST)
14. ROAD CLOSURE; IF NEEDED, PLEASE COMPLETE FC FORM 420-E (FORT CARSON UTILITY OUTAGE/CONNECTION REQUEST
14. ROAD CLOSURE; IF NEEDED, PLEASE COMPLETE FC FORM 420-E (FORT CARSON UTILITY OUTAGE/CONNECTION REQUEST
a. MILITARY POLICE
a. MILITARY POLICE
a. MILITARY POLICE
b. MEDDAC AMBULANCE 526-7112
b. MEDDAC AMBULANCE 526-7112
b. MEDDAC AMBULANCE 526-7112
c. FIRE PREVENTION 526-0651
c. FIRE PREVENTION 526-0651
c. FIRE PREVENTION 526-0651
15. RANGE CONTROL 526-5597
15. RANGE CONTROL 526-5597
15. RANGE CONTROL 526-5597
16. DPW TRAFFIC CONTROL 526-9267
16. DPW TRAFFIC CONTROL 526-9267
16. DPW TRAFFIC CONTROL 526-9267
17. POST AGRONOMIST 526-1666/1696
17. POST AGRONOMIST 526-1666/1696
17. POST AGRONOMIST 526-1666/1696
FC FORM 86-E, JAN 2015 (Back)
PREVIOUS EDITIONS ARE OBSOLETE
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CONTRACT PRIOR TO:
CONTRACT PRIOR TO:
CONTRACT PRIOR TO:
1. ANY PROJECT THAT REQUIRES THE PLANTING OR DIGGING UP OF TREES AND BUSHES.
2. ANY PROJECT BEING DONE DOWNRANGE.
3. ANY PROJECT REQUIRING GROUND DISTURBANCE OR GREATER THAN ONE (1) ACRE.
18. REMARKS: THIS SECTION MUST DESCRIBE SPECIFIC PRECAUTIONARY MEASURES TO BE TAKEN BEFORE AND DURING WORK. SPECIFIC COMMENTS CONCERNING THE APPROVED METHOD OF EXCAVATION, HAND, OR POWERED EQUIPMENT SHOULD BE INCLUDED. NOTE: BORING: ALL UTILITIES MUST BE EXPOSED BEFORE CROSSING.
18. REMARKS: THIS SECTION MUST DESCRIBE SPECIFIC PRECAUTIONARY MEASURES TO BE TAKEN BEFORE AND DURING WORK. SPECIFIC COMMENTS CONCERNING THE APPROVED METHOD OF EXCAVATION, HAND, OR POWERED EQUIPMENT SHOULD BE INCLUDED. NOTE: BORING: ALL UTILITIES MUST BE EXPOSED BEFORE CROSSING.
18. REMARKS: THIS SECTION MUST DESCRIBE SPECIFIC PRECAUTIONARY MEASURES TO BE TAKEN BEFORE AND DURING WORK. SPECIFIC COMMENTS CONCERNING THE APPROVED METHOD OF EXCAVATION, HAND, OR POWERED EQUIPMENT SHOULD BE INCLUDED. NOTE: BORING: ALL UTILITIES MUST BE EXPOSED BEFORE CROSSING.
19. TROOP CONSTRUCTION:
19. TROOP CONSTRUCTION
19. TROOP CONSTRUCTION
IMPORTANT - READ BEFORE SIGNING
The undersigned understands that the Fort Carson Base Operations and Maintenance contract locators will attempt to locate the underground utility lines by using electronic detectors, maps, and other available information, but that all such methods may be inaccurate. Therefore, it is expressly understood and agreed between the undersigned and Fort Carson that NO GUARANTEES OR WARRANTIES, EXPRESSED OR IMPLIED, ARE MADE BY FORT CARSON as to the accuracy of any information furnish. Depth of bury, when provided, is never guaranteed. Twenty four inches either side of the stake, paint marks, or flag is considered a correct horizontal location for government owned utilities. When utilities cannot be electronically located, their approximate location will be drawn on the attached Underground Utility Location Map (Form.4.34.003). All identified utilities must be exposed before crossing or paralleling within three feet of the existing utility to determine bury depth. It is the responsibility of the undersigned and/or excavating company to pot hole or hand dig these identified utilities. All damages to any utilities by any person must be reported immediately so an investigation can be made to determine the cause of damage and arrangements made for necessary repairs. WHEN THE GOVERNMENT INVESTIGATOR DETERMINES THAT THE EXCAVATING COMPANY WAS AT FAULT AND DISREGARDED THE ABOVE MENTIONED INSTRUCTIONS, THE DIG PERMIT WILL BE TERMINATED. Locates are good for 30 days, unless extended by the government, and all utilities will be marked once, then it is the contractors responsibility to maintain the marks.
(SIGNATURE)
SIGNATURE
SIGNATURE
(DATE)
DATE
DATE
(PRINT NAME)
PRINT NAME
PRINT NAME
(DATE)
DATE
DATE
(PRINT NAME)
PRINT NAME
PRINT NAME
(SIGNATURE)
SIGNATURE
SIGNATURE
10.0.2.20120224.1.869952.867557
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