Public Manhole Access Application

Name of Applicant Firm or Government Agency: *  

Purpose of the Permit: *  

Specific Performance Time Period.  (Access by the Applicant either before or after the stated time period shall constitute a violation of this Regional Wastewater Reclamation Department Directive). For Type 3 Access only, the activation date cannot be any sooner than two full business days from the date of application to allow for staff review.

Permit Activation Date: *  

Permit Termination Date: * 

Type 1 Access– Visual access of the public sanitary sewer system only.  (Physical entry into the public sanitary sewer system by employee of the applicant is not authorized).

Type 2 Access– Non-Physical Access of the public sanitary sewer system to allow only the insertion and removal of tools or equipment below the rim of the manhole cover. No human body part may break the plane of the manhole cover rim. The tools or equipment to be inserted in the manhole are identified as follows:

Type 3 Access– Physical Access and Permit Required Confined Space Entry by applicant’s employee into the public sanitary sewer system. See Certifications below.

Street Address: *   City: * 

State: * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming     Zip code: *  

Manhole Identification Number: *  

Manhole Identification Number:   

Manhole Identification Number:   

Major Cross Streets: *  

Right of Way Access:  The Permitee is responsible for the jurisdiction’s Right of Way use permit, all traffic control and safety compliance measures necessary to protect the public and employees, and any other permits required to perform the work.

Certifications

Applicant certifies, by signature below, that when this permit is marked for “Physical Access and Entry” above, then the employees that are to perform the work (including the physical entry) shall:

1. Be properly equipped with industry-standard confined-space entry safety equipment and atmospheric monitoring equipment suitable for a hazardous sanitary sewer environment.
2. Have been trained in and will employ OSHA confined-space entry safety procedures (29 CFR §1910.146 or successor provisions).

Permit Conditions

1. Upon request, applicant will provide RWRD with a copy of the written confined space entry procedures that will govern the confined space entry and/or the training records of the individuals that will physically perform the confined space entry.
2. The applicant will indemnify, defend, and hold harmless Pima County, its officers, departments, employees, and agents from and against any and all suits, actions, legal or administrative proceedings, claims, demands, or damages of any kind or nature which result from any act or omission of applicant, its agents, employees, or anyone acting under its direction, control, or on its behalf unless due solely to county negligence.
3. The Sanitary Sewer Access Permit shall neither constitute nor replace the Confined Space Entry Permit that the applicant must issue, in accordance with the applicant’s written confined space entry procedures as required for OSHA compliance, at the site of and at the time of the physical confined space entry.

By electronic submission of this permit application, I hereby certify that all of the information I have provided is true and correct, that I am duly authorized to submit this application on behalf of the permit applicant, and that the permit applicant will fully comply with all conditions of the permit.

*By(Name):  * Date: