Company Name Document No.

ZETA CONSTRUCTION PLC ZETA-OF-1018

EXCAVATION PERMIT FORM Revision Page
Title No. 00 1 of 3

DATE:

This permit will remain at the work site until the work is completed or a new
permit is issued. If conditions change within the excavation, all persons must
be evacuated until the conditions are evaluated and a new permit is issued.
Expired permits must be returned to the HSE/facility recordkeeping center for
filing.
Date Issued: Date Expires:
Specific Location of Work:
Purpose of Excavation:
TRACK completed for this task (Initials):

Feet Long Feet Wide Feet Deep

Stairway(s)
Ramp(s)
Stable Rock
Type A
Type B
Type C
Electrical Drainage
Communications Acid
Fuel / Oil Natural Gas
Water Sewer
Process Other (specify)
Steam
OTHER KNOWN OBSTRUCTIONS:
Footings Encasements
Pilings Other (specify)
Tanks
CONTROL REQUIREMENTS:
Shoring Sloping at angle
Trench Box Material and equipment 2 feet from edge
PRECAUTIONS:
Properly Isolated Ground Tools
Lines
Hand Excavation Hot Work Permit
Confined Space Other (specify)
Permit
WARNING SYSTEMS:
Barricades Lighting
Signaling Devices Flagman (with appropriate vests)
Approved By:
Competent Person
 Company Name Document No.
ZETA CONSTRUCTION PLC ZETA-OF-1018
EXCAVATION PERMIT FORM Revision Page
Title No. 00 2 of 3

Print Name Signature Date

MAXIMUM ALLOWABLE SLOPES (HORIZONTAL: VERTICAL) FOR

EXCAVATIONS LESS THAN 20 FEET DEEP
Soil Type Definitions Slope
STABLE ROCK - Natural solid mineral matter that can be Vertical or
excavated with vertical sides that remain intact while 90
exposed.
TYPE A – Cohesive soil example: Clay, slit clay, sandy clay, ¾:1 or 53
clay loam, which is not fissured or subjected to vibration
from heavy traffic etc., and has not been previously
disturbed.
TYPE B – Cohesive soil or granular cohesion less soil 1:1 or 45
including angular gravel, silt, silt loom, sandy loom.
Previously disturbed soils except those otherwise classified as
Type C.
TYPE C - Granular soils including gravel, sand, and loamy 1.5:1 or 34
soils or submerged soil.
Notes: (1) If soil type is undefined, assume to be Type C.
(2) Materials or equipment shall be kept a distance or at least two
feet from the edge of the excavation.

Stable Rock
Vertical or 90º Type A
¾:1 or 53º

Type B
1:1 or 45º

Type C
1.5:1 or 34º

Excavation Inspection Log

(Excavations greater than four feet deep must be completed daily and as
needed throughout the shift)
Date Time Inspector’s Signature
 Company Name Document No.
ZETA CONSTRUCTION PLC ZETA-OF-1018
EXCAVATION PERMIT FORM Revision Page
Title No. 00 3 of 3

Upon completion of work, forward permit to HSE/recordkeeping

center.