CARILLION GROUP FORM
HEALTH, SAFETY, SUSTAINABILITY & QUALITY
Permit to Disturb Ground
PLC/CORE/HSSQ/PRO/084-F003
Part 1 – Until Stage 4, this permit is only valid for the hand digging of trial holes to confirm the location of known services
All Trial Holes must be hand dug as prescribed within HSG 47 i.e. commencing off the line and working towards the service
Contract Name:
Permit Number:
Part 2 – Once the 3 stages overleaf have been completed, the decision to proceed is required based on the following points.
Stage 4
At this stage the permit must be reviewed by the receiver and the issuer where discussions will take place in
order to progress with the main works
Contract No:
Date:
/
Do any services require isolation?
Yes / No
Isolation permit required?
Yes / No
Location of Work:
Expected Depth:
mm
Do any services need to be re-routed?
Yes / No
Do any services need to be protected?
Yes / No
Activity:
Maximum Depth:
mm
Date Permit Suspended (if Required)
/
Method of Support Documented?
Yes / No/ N/A
Method of Access Documented?
Yes / No
Method of Edge Protection Documented?
Yes / No
Is a Temporary works design required?
Yes / No
Confined space?
Additional Permits Required? E.g. pump
Yes / No
If required, have suitable precautions been taken to prevent undermining or damage to foundations or
temporary supports?
If present, have precautions been taken to prevent contact with overhead services or near approach to the
operation?
Is the work likely to be effected by changes in weather conditions / temperatures?
Yes / No
Is the work to be carried out in areas known to contain contaminated soil?
Yes / No
Cat No
Yes / No
Yes / No
Calibration Date
/
/
Service Identification
1 – Desktop Study
Stage
2 – Field Study
Other eg Overhead,
Fire hydrant, asbuilt,
Verified via
Present?
Trialhole?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Trial holes checked?
Signed (Approver)
Sign:
Sign:
Electricity UG/OH?
Gas / Fuel
Communications
High Pressure Lines
Water
Sewers
Drainage
Sign:
Yes / No
Method Statement No detailing
method of excavation
NO MECHANICAL EXCAVATION MAY TAKE PLACE WITHIN 500mm OF ANY IDENTIFIED SERVICES
Name
Position
Sign
Date
Services located and
Cannot be the
mechanical excavation
same person
authorised by Permit
through all stages
issuer
Permit Close Out: The work associated with this permit is complete / ceased – No further excavation work may be carried
out in this location without the issue of the new permit.
Permit Coordinator
The permit is to be closed by the contract permit
Sign
Date
Name
coordinator who will ensure any uncharted, disconnected
Stage 5
or newly installed services have been recorded for any
future excavations.
3 – Trial Holes
Service identified
Identified via
Identified by CAT
Drawing number?
on drawing?
visual inspection? / Genny / Radar?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Drawings and info checked?
Inspections checked?
Service
Is a review of the RAMS required?
Yes / No
Cat and Genny to be used prior to disturbing the ground and at regular periods throughout the activity
Cat and Genny User
Date Permit reviewed and re-issued
All persons involved in this excavation must be briefed on the contents of this permit
We the undersigned have received, read and understood the content, controls and arrangements specified in the
attached permit and agree that If during excavation any unrecorded services or unidentified buried objects are
uncovered, or underground apparatus damaged – work must be suspended and emergency contact informed
immediately:
Name
Position
Employer
Signature
Date
Specific excavation requirements: Where it is foreseeable that underground apparatus may be struck (based on risk assessment);
Insulated tools to BS 8020 must be used and flame retardant work wear to be worn.
Permit Validity
(First 7 Days)
Permit
Start:
Permit Receiver to Sign:-
Date:
/
Time:
:
/
7 Day
Expiry:
Date:
Time:
/
/
:
Signature:
28 Day
Expiry:
Date:
Date:
/
/
Time:
/
:
/
NOTE:- The Permit Receiver MUST have completed the 1 Day Underground Services Course and hold CSCS gold card
Periodic
Date:
/
/
Date:
/
/
Date:
/
/
Extension
Day
Day
Day
(Agreed By;
Sign:
Sign:
Sign:
8 -14
15-21
21-28
permit receiver
Sign:
Sign:
Sign:
and GF)
Extension of this permit can only proceed if there are no changes within the original scope of work
Name
Stage 1
Stage 2
Stage 3
Rev 005
Permit prepared and
issued by:
Underground apparatus
identified by:
Trial Holes dug and
underground service
confirmed by:
Position
Sign
Date
/
/
/
/
/
/
Date of Issue 14/10/13
See procedure ref – Permit to Work - PLC/CORE/HSSQ/PRO/084
Page 1 of 2
CARILLION GROUP FORM
HEALTH, SAFETY, SUSTAINABILITY & QUALITY
Permit to Disturb Ground
PLC/CORE/HSSQ/PRO/084-F003
Sketch of work area showing areas scanned, marked and where Trial holes have been excavated. Trial holes to be shown using TH on sketch
Plan
Section
Key
Sketch Author
Scale
Date Drawn
Revision
If any major services are highlighted or subsequently located work must stop until advice from Utility Provider is sought and a specific method statement created.
Rev 005
Date of Issue 14/10/13
See procedure ref – Permit to Work - PLC/CORE/HSSQ/PRO/084
Page 2 of 2