TRENCHING / EXCAVATION PERMIT:
Reference
Trade:
Excavation Supervisor:
Description of trench / excavation works (include depth, size):
Location of trench / excavation works:
Signature of Person Completing this Form:
Sign
Hazard Checklist
Before You Dig Australia asset location plans obtained?
Yes
No
N/A
Notes
All underground services located and marked?
Yes
No
N/A
Notes
Has in ground services been located by hand excavation (potholing)
Yes
No
N/A
Notes
Are overhead powerlines in the vicinity?
Yes
No
N/A
Notes
Is a qualified spotter/safety observer required? (in-ground / overhead)
Yes
No
N/A
Notes
Is a permit from an inground / overhead asset owner(s) required for the works?
Yes
No
N/A
Notes
Traffic managed addressed (onsite & offsite / public)
Yes
No
N/A
Notes
Undermining of adjoining structures assessed?
Yes
No
N/A
Notes
Possibly of flooding reviewed (drain, water runoff, etc)
Yes
No
N/A
Notes
Nature of ground assessed? (soil/rock/sand/clay, wet/dry, etc)
Soil
Sand
Wet
Rock
Clay
Dry
Notes
Shoring and ground support requirements assessed?
Yes
No
N/A
Notes
Draw a sketch below of the ground collapse prevention system to be used for the trenching / excavation work (include maximum depth, maximum vertical face measurements, batter degree angle or shield when installed).
Notes
Are hazards and control measures associated with the trenching / excavation works (including rescue procedures) covered in a safe work method statement
Yes
No
N/A
Notes
Safe means of access and egress provided?
Yes
No
N/A
Notes
Fall hazards assessed (excavation work over two metres deep)
Yes
No
N/A
Notes
Excavation / trenching works secured from public access
Yes
No
N/A
Notes
Have the ground conditions within the zone of influence been inspected for fretting, slipping, slumping or ground swelling prior to entry?
(Inspection to be completed before a person enters an excavation where they have the potential to be engulfed in a ground collapse)
Yes
No
N/A
Notes
Name of person inspecting ground condition
Notes
Does the shoring, battering, trench walls, shield and / or ground support system comply with the requirements of the geotechnical report / engineer design requirements prior to a person entering the excavation?
Yes
No
N/A
Notes
Name of person inspecting ground conditions / support system:
Notes
Are contaminated soil hazards and control measures documented is a safe work method statement? (refer to hygienist / contaminated soil report)
Yes
No
N/A
Notes
Sign Off
Contractor Sign-off
Sign
Permit Revision
Approver Name & Signature
Sign