Professional Documents
Culture Documents
F0206
Excavation and Trenching Permit – Example 1
Verified By Date
Walkdown to ensure:
Supervisor:
Ground markings identifying underground obstructions
are present and applied in accordance with 000.653.3311.
Evaluation of the work area for potential hazards that
have not been addressed by scanning existing drawing Competent
research efforts and/or other pre-task planning activities. Person:
Excavation work is released to begin.
Supervisor:
(Supervisor)
Copyright © 2009, P2S. All Rights Reserved. Page 1 of 5 Health, Safety, and Environmental
Form Date: 01May2009
Form 000.653.F0206
Excavation and Trenching Permit – Example 1
Copyright © 2009, P2S. All Rights Reserved. Page 2 of 5 Health, Safety, and Environmental
Form Date: 01May2009
Form 000.653.F0206
Excavation and Trenching Permit – Example 1
The excavation permit is valid, signed, and dated. Excavation began within 60 days of facility/system owner’s signature or by the
permit expiration date.
Employees have received a daily briefing on the composite scan drawing, the excavation/trench’s special requirements, and
excavation hazards.
The area surrounding the excavation/trench has been properly protected and barricaded.
Ensure “U DIG” has been notified 10 days before excavation and every 10 days during excavation (as/if applicable).
Utilities have been located, protected, and marked (refer to composite scan drawing).
The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored.
Protective systems being used comply with the manufacturer’s instructions or engineering designs.
Sloping or protective systems have been checked for evidence of failure (such as soil distress, structural member damage, or soil
fissures).
A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) of each person in the
excavation/trench.
Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench.
Excavated materials have been placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench.
A determination has been made whether or not to classify the excavation/trench as a confined space.
Note: If the excavation/trench is classified as a confined space, ensure monitoring (as required on the confined space entry
permit, if any) is performed before employees are allowed to enter.
Pre-task planning documents have been updated, as required, to reflect changes in work scope, site conditions, or hazard change.
Planning documents have been discussed with, and signed by, affected employees.
Copyright © 2009, P2S. All Rights Reserved. Page 3 of 5 Health, Safety, and Environmental
Form Date: 01May2009
Form 000.653.F0206
Excavation and Trenching Permit – Example 1
Permit No.
EXCAVATION PERMIT
1. Work Package No. 2. Task/Project No. 3. Location of Excavation
4. Originated By Date 5. Change Notice
6. Drawings Required (identification No.) 7. Other Affected Drawings or Documents (if any)
8. Description of Work (attach composite drawing of excavation location and all known interferences)
Yes No
Within 25 feet (7.6 meters) of the center line of a railroad track?
Approvals
12. Construction Supervision Date
Copyright © 2009, P2S. All Rights Reserved. Page 4 of 5 Health, Safety, and Environmental
Form Date: 01May2009
Form 000.653.F0206
Excavation and Trenching Permit – Example 1
Block 5 If associated with a change notice (such as DCN, ECN, FMP, etc.), enter the number.
Block 7 List other drawings or documents affected by the excavation work, if any.
Block 8 Describe the purpose of the excavation work. Attach a composite drawing identifying each of the
areas to be excavated and all known interferences.
Block 9 Enter special instructions/comments or requirements relating to the excavation, such as safety
requirements or additional required permits. Identify required pre-excavation scanning, if any,
and specify.
Block 11 List utilities, services, and facilities that either will, or may be, affected by the excavation.
Copyright © 2009, P2S. All Rights Reserved. Page 5 of 5 Health, Safety, and Environmental
Form Date: 01May2009