Trenching & Excavation Permit

NOTICE: A Trenching and Excavation Permit is required for all excavations that penetrate the ground surface.

Date*

Date

State

Project Name*

Project Number

Job Supervisor*

First NameLast Name

Supervisor Email*

example@example.com

Equipment Operator(s)*

Location where excavation will occur

Description of excavation

Excavation Size

Is this a printed/paper permit

Yes

Upload printed permit or any supplementary documents

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Will workers enter trench

YesNo

Atmosphere Checks

Oxygen shall read between 19.5% and 23.5%

LEL must read 0%

Means for Egress

StairwaysRampLadder(s)Other

Before Excavation (All soil will be considered type 'C' soil)

	Yes	No
One call been performed
Overhead and underground utilities been identified and marked
Owners of utilities, service, or transmission piping been identified (electrical, telephone, water, sewer)
Pilings will be set back at least 18 inches
Changing ground condition(s) anticipated (particularly after rain fall)
Monitor for possible oxygen deficiency or gaseous conditions
Adequacy of shoring and/or sloping as work progresses
Water removal equipment available if needed
Portable trench boxes or trench shields available if needed
Check for previously disturbed ground conducted
Adequacy of all equipment, including personal protective gear, shoring material, signs, barricades, and machinery
Proper sloping

Excavations over 5' feet in depth

	Yes	No
Sloping and benching adequate
Timber shoring for trenches
Aluminum hydraulic shoring for trenching
Alternative to timber shoring
Selection of protective systems
Designed shoring (data must be filed on site).
Is trench deeper then 20' feet? Note: Sloping or benching for excavations greater than 20 feet (6.1 meters) deep must be designed by a registered professional engineer.

Measures taken where the above conditions are not achievable

Share drawings or plans designed for this specific excavation activity

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Site Manager(s) Name(s)

Competent Person(s) Name(s)

Equipment Operator(s) Name(s)

Entrant(s) Name(s)

Controls