Title Page
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LMJ
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MMJ
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DUCT SECTION NUMBER
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Prepared by (engineers name)
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PIANOI
Details
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A55 Requirement
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Type of Blockage
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Select Cover Type (1st Chamber)
- JUF4
- JUF6
- JUF2
- JUF10
- M/H
- JRC12 (C/W 2 Lids)
- JRC14 (C/W 3 Lids)
- CW1 (C/W Manhole)
- Pole Up Turn
- Locked Chamber
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Chamber Location
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Image of Chamber ONE SURROUNDING , ONE INTERNAL , ONE DUCT WITH ROD
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What is the Surface Type
- Footway (Tarmac)
- Footway (Slabs)
- Footway (Concrete)
- Carriageway (Tarmac)
- Carriageway (Slabs)
- Carriageway (Concrete)
- Soft Verge
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Blockage location
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Distance to Blockage from 1st Chamber
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X Marks the spot photo (photo required for each blockage location if there are 2 blockages on 1 section) including surrounding reference point
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Is there additional blockages?
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Location of Second blockage
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Blockage distance from 2nd chamber
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Can minimum footway distances be maintained?
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Is carriageway inclusion required?
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Void Distance (if appropriate)
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Select Cover Type (2nd Chamber)
- JUF4
- JUF6
- JUF2
- JUF10
- M/H
- JRC12 (C/W 2 Lids)
- JRC14 (C/W 3 Lids)
- CW1 (C/W Manhole)
- Pole Up Turn
- Locked Chamber
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2nd Chamber Location
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Image of 2ND Chamber ONE SURROUNDING , ONE INTERNAL , ONE DUCT WITH ROD
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3m rods used
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Duct Section Number
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Image of Duct Section (Client/Openreach Maps)
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Overhead solution available?
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Issue
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DP ID
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DP ID Image
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Location
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Image of Duct/Pole Section (Client/Openreach Maps)
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Image Overview of Pole (Must be front/back and both sides)
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Image Overview of Pole Top (Must be 4 Faces of the Pole )
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Pole Location
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Image of Pole Bend
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DP ID
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Image of DP ID
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What is the Surface Type
- Footway (Tarmac)
- Footway (Slabs)
- Footway (Concrete)
- Carriageway (Tarmac)
- Carriageway (Slabs)
- Carriageway (Concrete)
- Soft Verge
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Select Cover Type (Lead-in Chamber)
- JUF4
- JUF6
- JUF2
- JUF10
- M/H
- JRC12 (C/W 2 Lids)
- JRC14 (C/W 3 Lids)
- CW1 (C/W Manhole)
- Pole Up Turn
- Locked Chamber
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Image of Lead-in Chamber (Must Show surrounding area)
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Image of cobra in duct
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Location
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Distance from lead in chamber to Pole Bend
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Duct Section Number
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Image of Duct Section (Client/Openreach Maps)
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Image of Marked Blockage
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Is there an overhead solution available
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First Chamber Location
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Image of First Chamber
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Second Chamber Location
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Image of Second Chamber
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Is carriage way incursion required?
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Can 1.2m be maintained on the footway ?
Sign-Off
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Engineer Sign-off
