Title Page
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Conducted on
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Job Number
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Asset Number
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Location
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Prepared by
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Works type
- Coupon Sample
- High Speed Pressure Monitor
- Pipe Wall Scanning
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Main type
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Main diameter
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Main depth
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Is the main concrete encased
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Main material
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Main material
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Breakout surface
- Grass
- Concrete
- Bitumen
- Gravel
- Dirt
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Turf, topsoil or grass seed required (Length and Width)
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Concrete cutting and restoration required (Length and Width)
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Bitumen cutting and restoration required (Length and Width)
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Proposed trench dimensions (Length x Width x Depth)
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Will the trench be greater than 1.5m in depth?
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Is there space for the trench be benched or battered?
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Extra equipment required
- Work at Height
- Confined Space
- Shoring
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Works location
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Road type
- White Road
- Yellow Road
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Subcontractors required for works
- Traffic Control
- Concrete Cutter
- Gas Spotter
- Pole Holder
- Bitumen
- Vacuum Excavation
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Traffic controllers required
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Vacuum excavation required for;
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Is the job site within the drip zone of any trees
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Distance from proposed trench to base of tree
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Additional materials required
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Additional comments
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Site photos
