THIS FORM SHALL BE COMPLETED PER JOB SITE FOR EXCAVATIONS OF 4 FEET OR MORE IN
DEPTH. APPROVAL SIGNATURES REQUIRED PRIOR TO JOB START
POST APPROVED FORM AT JOB SITE
Newtown: (215) 497-2002
Date: _________________________ Building/Area:
Purpose of this excavation:
Project Description: _____________________________________
Contractor (If applicable): _______________________Competent Person: _________________________
Underground Utility Locator Company: _______________________________________________________
Is shoring required? YES____ NO____
(NOTE: If excavation is over 5 feet deep, shoring or a 1½ to 1 tapered slope is required)
FACILITY OPERATIONS & SERVICES PM (Name/Signature):
Paving involved: Yes_____
Concrete involved: Yes_____
No_____
No_____
Re-compacting needed (95% on the proctor scale): Yes_____
Backhoe
_____
Front-end loader_____
Electrical lines present: Yes_____
Piping lines present: Yes_____
No_____
No_____
No_____
Grader_____
Posthole digger_____
Buried_____
Buried_____
Overhead_____
Other_______________
Marked: Yes____
Overhead_____
No_____
Marked: Yes____ No______
INFORMATION TECHNOLOGY REP. (Applicable signature required):
Steve Carignan (215) 497-2070 __________________________________________ (Signature)
IT lines Present: Yes_____ No_____ Buried_____ Overhead_____
Copper_____
Fiber____
Qwest_____
ENVIRONMENT, SAFETY & HEALTH REP. (Applicable signature required):
Jen Cole (215) 497-2002 ________________________________________________ (Signature)
Storm water permit required if disturbance is 1 acre, black zone map, spoils, water diversion, groundwater,
erosion controls, duration > 5 days. A copy of this signed permit must be forwarded to ESH.
Post Permit in work area prior to work

Construction is complete when all disturbed areas are stabilized with asphalt, cement, riprap, or
vegetation.

Place dirt piles up-hill of excavation to channel any sediment loading into the excavation.

If the total project disturbed acreage approaches one acre, a Phase II Stormwater Construction
Permit is required.

Projects crossing streams and construction in a streambed or wetland require Army Corps 404
permitting. Crossing streams is discouraged. Contact ESH prior to crossing/working in streambeds
and/or wetlands.

Groundwater monitoring wells may not be disturbed. Damaged wells will require immediate
repair or replacement.

Waste asphalt and cement must be shipped off-site or recycled but not as fill.
Newtown ESH Contacts:
Melanie Dickersbach (215) 497-2415 (Water, Erosion Controls, Groundwater Wells, Waste)
Bob Arnott (215) 497-1309 (Trenching/Shoring)