TE DIG1, Fort Belvoir Excavation Permit.doc

Expiration Date of Permit: ____________________ Permit #: __________

MARKINGS MUST BE MAINTAINED

U.S. ARMY GARRISON, FORT BELVOIR

DPW EXCAVATION PERMIT

A. REQUESTER _ ___________ B. EXCAVATION RISK: DPW NEC EXPIRATION

P.O.C.: ______________ CLASS I (SEVERE) ______ ______ 15 DAYS

Tele #: _____________

Date Clearance Required: _______ CLASS II (MINIMAL) ______ ______ 30 DAYS

___Email Address:____________________________________________________ C. LOCATION OF AREA TO BE EXCAVATED: Do not put “see attached”, need an actual location listed.

(NOTE: A to-scale drawing of the excavation site (highlighted, 7 copies of drawing) must be submitted along with this form. Excavation route must be staked, painted or flagged by the requester every 30 feet.)

D. TYPE OF WORK TO BE PERFORMED: Adding conduit from manholes to generators underground

E. MISC INFORMATION:

(1) This excavation request is used for any work on post that may disrupt underground utilities, communications, right of ways or any routine activities.

(2) Processing of this permit will take approximately 10-14 working days. Requester must have an approved excavation permit prior to commencement of work, and permit must be kept on-site.

(3) If utilities or communications have been located in the area to be excavated, hand digging will be used within 3 foot radius until the exact location of all lines has been determined. If markings are maintained by the requester, an extension may be given to the expiration date if needed.

(4) The Government reserves the right to have on-site personnel present during any excavation and will specify on this permit under precautionary measures if needed.

(5) The requester shall protect from damage all existing improvements, utilities, communications and vegetation at or near the work site. The requester shall be liable for all damages to persons or property that occur as a result of the requester’s fault or negligence.

(6) If any work is within FBRC/Michaels Lease Line, pick up additional dig permit instruction sheet.

(7) Any questions regarding this excavation permit may be directed to the Utility Services Officer at 703-806-3765.

I HAVE FULLY READ AND UNDERSTAND THE ABOVE NOTES

Signature of Contractor / POC Date

F. REQUESTER ACTION # 9 & 10 (See items G on back of form for directions) Risk Assessments if Damage Occurs Initial/Date Facilities/Areas Effective

(1) Business Mgmt. ________________

(2) Aleut Work Order #_______________________

Electrical ________________________________________ ________________

Mechanical ________________________________________ ________________

Sanitation ________________________________________ ________________

(3) Fire Prevention ________________________________________ ________________

(4) Environmental ________________________________________ ________________

(5) Master Planning ________________________________________ ________________

(6) Provost Marshal ________________________________________ ________________

(7) NEC ________________________________________ ________________

(8) Safety Office ________________________________________ ________________

(9) Miss Utility # ________________________________________ ________________

(10) FBRC/Michaels ________________________________________ ________________

PRECAUTIONARY MEASURES: __________________________________________________________

G. DIRECTIONS FOR REQUESTER ACTION:

(1) Business Mgmt. 9430 Jackson Loop, ATTN: Janet Lower, Rm 137. Initiate Excavation

703-806-3925 Permit at least 15 days prior to commencement of work.

(2) Aleut 9460 Jackson Loop, Attn: Becky Milam, Business Management Division

703-806-4798 will forward to Aleut.

(3) Fire Prevention 9701 Gunston Road, Bldg. 191 Fire Inspector's Office for signature on 703-805-2091 permit for any work that may result in a road closure.

(4) Environmental 9430 Jackson Loop, Rm 227. Environmental Office.

703-806-4142

(5) Master Planning 9430 Jackson Loop, Rm 220. Master Planning Office

703-806-0043

(6) Provost Marshal 6080 Abbot Road, Bldg. 2124 Operations Office for signature on permit for 703-806-3104 any work that may result in a road closure.

(7) NEC 10105 Gridley Road, Bldg. 312, Rm. 201 ATTN: Rondell Briggs.

703-704-1005

(8) Safety Office 6001 5th Street, Bldg. 1471 ATTN: Scott Bruning, Fort Belvoir is a 703-806-3447 Federal OSHA VPP site, and the safety record of potential contractors may be examined. All work shall comply with OSHA safety laws & industry standards. Report accidents to Safety at (703) 806-3454.

(9) Miss Utility Call Miss Utility at least 48 hrs in advance of excavation.

800-552-7001 Provide all information Items A & C on the front of this form. A or 811 Ticket number will be provided by Miss Utility. Must be updated every 14 days.

(10) FBRC/Michaels 6024 16th Street, Bldg. 1108 Housing Maintenance Manager Office for 571-278-5633 Signature on permit for any work in the FBRC/Michaels lease line.

or 571-722-3560 (See attached Dig Permit Instructions for FBRC/Michaels lease line).

(11) DPW Utilities 9430 Jackson Loop, ATTN: Alicia Hart, Rm 137. Contractor/POC must 703-806-3765 obtain approval of excavation permit prior to commencement of work.

H.

Approved _________ Name and Title of Authorizing Official

Disapproved ______

Alicia Hart Date

Utility Services Officer Directorate of Public Works FB (DPW) FORM 75R, October 2016 Previous editions are obsolete