Corporate Safety - Form
Excavation and Trenching Permit
Section 1 – Details of work (Permit Recipient to complete)
Site name
Work Order #
Location on site
Details of work to be
undertaken
Date of work
Planned finish date
This permit is required to be completed:


for any work on a brownfield site* that involves excavation or trenching work ≥ 300mm in depth or driving
an object ≥ 300mm into the ground
where a worker is required to enter an excavation or trench on either a greenfield or brownfield site*
greater than 1.5m in depth or where there is a risk of engulfment due to poor ground conditions*.
Section 2 – Excavation and trenching checklist (Permit Recipient to complete)
Any work on a brownfield site ≥ 300mm
All underground services in the area have been positively located and appropriately marked by:
Site plans reviewed Y ☐ N/A ☐
Dial Before You Dig
Non-destructive testing Y ☐ N/A ☐
Y ☐ N/A ☐
(call 1100)
planned
The area affected by the work has been barricaded and signs installed
Y ☐ N/A ☐
Exclusion zones established (min 2 meters from the edge) to manage falling objects, spoil, plant, etc.
Y ☐ N/A ☐
An environmental assessment is required due to:
☐ contaminated land
☐ acid sulphate soil
☐ Vegetation Protection Order in place
☐ fire ants ☐ work in a waterway or coastal area
Y ☐ N/A ☐
☐ cultural heritage ☐ other:
Work is adjacent to buildings or other critical assets or in areas where poor ground conditions are
present – if YES assessment by geotechnical engineer required.
Engineer name:
Signature:
Date:
Y ☐ N/A ☐
Overland water management controls have been implemented.
Y ☐ N/A ☐
Sedimentation management controls have been implemented.
Y ☐ N/A ☐
Dust management controls have been implemented.
Y ☐ N/A ☐
Overhead or underground electrical lines present in the area of work.
Spotter name:
Y ☐ N/A ☐
Worker required to enter an excavation or trench
Y☐
High Risk Work Rescue Plan (TEM-00027) developed.
Which of the following ground collapse controls will be implemented to prevent engulfment:
☐ Shoring ☐ Benching & Battering
☐ Trench Box
☐ Other:
Entry and exit points confirmed (ladders at 9m intervals along the trench and protruding at least 1m
above ground, ramps or steps used).
Y ☐ N/A ☐
Standby person / spotter is appointed and in place for the duration of the work.
Name:
Y ☐ N/A ☐
Additional risk controls, instructions or information:
Doc no.
Doc owner:
FRM-00413
J. Paige
Version date:
Trim ID:
27/03/15
Doc approver:
Rev no.
Manager, WHS
The controlled version of this document is registered. All other versions are uncontrolled
3
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Corporate Safety - Form
Excavation and Trenching Permit
Section 3 – Verification of risk controls (Permit Recipient to complete)
I confirm that actions and risk controls required in Section 2 have been implemented for the work to be undertaken as
described in Section 1. Workers involved in this work have been advised of, and understand, the requirements and risks
of this work.
Note: This permit is activated at the time that the Permit Recipient completes and signs Section 3 and is valid for the
period of work defined in Section 1.
Permit recipient
name
Signature
Date
Time
Section 4 – Completion of work (Permit Recipient to complete)
I confirm that the work defined in this permit has been completed in accordance with the requirements of this permit.
All spoils, plant, tools and equipment have been removed from the work area and that the work area has been left in a
safe condition, with appropriate sediment management controls in place to manage any sediment generated from any
area of soil disturbed as a result of undertaking the work defined in this permit.
Permit recipient
name
Signature
Date
Time
*Notes

Poor Ground Conditions are defined as ground conditions where there is an increased risk of collapse due to one
previously dug soil, the existence of filled land, presence of groundwater or sand. When there is any doubt regarding
ground conditions in an area where an excavation or trench is planned, geotechnical advice should be sought and
appropriate risk control measures implemented.

Brownfield Sites are defined as land currently or previously used for industrial purposes or some commercial uses. It
includes any land that is not a greenfield site. Brownfield sites have greater risks of the presence of underground
services or contaminated soils.

Greenfield Sites are defined as undeveloped land in a city or rural area either used for agriculture, landscape
designs, or left to evolve naturally and which is free of underground services or contaminated soils.
Underground service marking colour requirements:
Service
Tape colour
Service
Gas
Yellow
Fire-fighting
Water
Green
Sewerage
Communications
White
Doc no.
Doc owner:
FRM-00413
J. Paige
Tape colour
Red
Cream
Service
Tape colour
Reclaimed Water
Purple
Electricity
Orange
Version date:
Trim ID:
27/03/15
Doc approver:
Rev no.
Manager, WHS
The controlled version of this document is registered. All other versions are uncontrolled
3
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