Safety Permit to Dig
Project Name:
Permit Number
Description of Works and Location:
(Dimensions, depths, chainage)
PART A: To be completed for ALL operations involving breaking ground Are there known/charted services in the location? (Tick)
Gas Property Connection Drains Unknown (Picked up on GPR)
Electricity Fibre Optic Traffic Signal
Water BT Street Lighting No services
If there are no services indicated (within the proposed are of dig) on an statutory drawings or topographical GPR survey, and the area has been CAT scanned and proved clear, then mechanical excavation can proceed, persons to be kept clear of machine bucket at all times Go to part B If CAT & Genny equipment is to be/has been used, must hold a valid 12 month Calibration Have all known services been traced and marked out on the ground?
Yes
No
If Electricity, gas or unknown services are present then trial holes MUST be dug using safe techniques (No breakers or mechanical equipment) and marked on the drawings to prove exact depth, location and direction. Have trial holes been done prior to this permit?
Yes
No
All known/charted services must be shown on the attached sketch(s) or relevant survey drawing, clearly stating the trial hole locations where required (Gas, Electricity, Unknown) Additional comments and notes:
(Specify details of equipment to be used to safely expose and identify any service
PART A: Issued by Person in Control of Works (PCW) If Electricity and or gas are located in the area then a nominated supervisor MUST be in place until the service is safely located by hand. Supervision?
Yes
No
If no Non-working supervision in place by then PCW MUST supervise until Electricity/Gas are located. If electricity or Gas is found to be encased in concrete the service MUST be diverted or isolated before commencing with the excavation works. If the service is not diverted or isolated then confirmation to proceed with mechanical methods MUST be received from the most senior
manager on site.
Page 1 of 4
A J Burgess
Safety Permit to Dig
(PCW) Print: Signed: Checked:
To be signed by Section Foreman/Supervisor to confirm that contents of permit have been understood
Print: Signed:
Date: Time: Date: Time: A copy of this permit must be kept with the supervisor of the activity at the workface
PART B: To be completed with reference to PART A, by PCW for ALL operations breaking Ground Have all known/charted services, been safely located, Yes No Services exposed and identified by trial holes? Identified
Has Electricity and or Gas been identified as present Yes in the area of dig or within 500mm of? If Yes, they MUST be fully exposed safely before commencing with mechanical means.
No No
Yes
Note: If Gas is located within the vicinity of the proposed work it is advisable to contact the service provider as a greater safety margin (more than 500mm), maybe required dependant on pressure of the main Notes/Comments:
Excavation by mechanical means may only proceed if: If known services within the immediate area of the proposed dig have been fully exposed by safe techniques under direct supervision OR There are no identified services shown on the survey drawing and nothing has been located with a CAT & Genny within 500mm either side of the proposed excavation line. PART B: Accepted by (Supervisor) To be signed by Section Foreman/Supervisor to confirm that contents of permit have been understood Signed Valid from: Until:
PART B: Approval to Proceed: Signed
Work must be suspended if services are damaged and reported immediately to Management A copy of this permit must be kept with the machine operator involved in the proposed activity. The supervisor must also brief the machine operator on the contents of the permit.
PERMIT TO BE SIGNED DAILY FOR WORKS TO PROCEED
Persons to be kept well clear of machine bucket even though no services have been located.
Page 2 of 4 A J Burgess
Safety Permit to Dig
PLANS/SECTIONS Show plan details (including known services), setting out details and trench details as applicable (attached additional sheets if required)
Page 3 of 4
A J Burgess
Safety Permit to Dig
DATE: TIME: ACCEPTED BY: AUTHORISED BY PCW
Page 4 of 4
A J Burgess
