Excavation Permit - Local

• Permit No.

• Conducted on

  Date
• Location
  Address

• Description of work

• Competent Person

• Personnel performing the work

• Type of excavating equipment to be used

  back hoe

  trencher

  other

• Client / Site

Excavation Checklist

• Excavation Dimensions; depth, width, length

• All existing underground lines identified

  Yes

  No

  Other

• Extra precautions must be taken if existing utilities can not be identified, i.e. hand digging, using toothless buckets, etc.

• Sloping shoring required

  Yes

  No

• Why not? Explain

• Soil type

  A

  B

  C

• All soil is considered Class C unless proven otherwise by methods outlined in OSHA 1926-650-652

• Water removal required?

  Yes

  No

• Any overhead hazards

  Yes

  No

• What precautions will be taken and employees informed of such precautions

• Proper barricading in place?

  Yes

  No

• Soil to be:

  removed

  returned to excavation

• Confined space entry permit required?

  Yes

  No

• Proper procedure established

  Yes

  No

• Why not?

• Special precautions required

• Notes:
  1. All excavations must be filled with clean, contaminant free dirt and well tamped.
  2. All soil is considered class C unless proven otherwise by methods outlined in OSHA 1926-650-652
  3. Removed solid must be piled away from excavation edge by at least 2 feet or where it may not fall into excavation.
  4. Excavations must be closed daily unless barricading is provided
  5. Extra precautions must be taken if existing utilities can't be identified i.e. hand digging, using toothless buckets.

  

This permit is issued with the understanding that work will be performed according to applicable OSHA regulations and JBI fire and Safety regulations.

• Competent person name

  Sign

Inspection Checklist: to be completed prior to personnel entry into excavation

• Barricades in place

  Yes

  No

  N/A

• shored

  sloped

  benched

• Monitors on site and operational (if monitored continuously )

  Safe

  At Risk

  N/A

• Ladders accessible within 25 feet?

  Safe

  At Risk

  N/A

• If shored all exposed sides covered?

  Safe

  At Risk

  N/A

• Shoring members are sound not bowing or cracking

  Safe

  At Risk

  N/A

• Spoil pile is at a safe distance from excavation (at least 2 feet)

  Safe

  At Risk

  N/A

• Is excavation dry?

  Yes

  No

  N/A

• Is water removal being performed

  Yes

  No

• If sloped of benched, proper slope ratio is being maintained?

  Safe

  At Risk

  N/A

• If shielded personnel working inside the shield?

  Safe

  At Risk

  N/A

• Full protection equipment is being utilized?

  Yes

  No

  N/A

• All open trenches inspected

  Yes

  No

  N/A

• Top of slope free of tension cracks

  Yes

  No

  N/A

• Trench walls free of evidence of shrinking cracks

  Yes

  No

  N/A

• Area clear of unusually weak soil or materials not anticipated?

  Yes

  No

  N/A

• Solid of rock free of evidence of significant fracture planes?

  Yes

  No

  N/A

• Bracing system installed in accordance with design

  Yes

  No

  N/A

• All short term trenches covered within 24 hours

  Yes

  No

  N/A

• Traffic area adequately away from trenching operations and controlled?

  Yes

  No

  N/A

• If any items are marked NO, they must be corrected before permits may be issued and work may begin.

• Competent Person Signature

  Sign