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1350 Rest Point Circle, Mound, Minnesota <br /> June 9, 2022(Rev. June 16, 2022) <br /> Page 14 <br /> • Statement of Conformance <br /> (for Retaining Wall Contractor) <br /> Project Name/Address: <br /> Form to be submitted with all construction progress photos by the retaining wall contractor at time of <br /> wall completion.This form is required in order to request a wall completion letter from CSE: <br /> Block type: <br /> Geogrid type: <br /> Description of site soils (i.e. sand, clay, loam): <br /> Leveling pad size and type of material: <br /> Embedment depth (courses of block buried): <br /> • Draintile type and diameter: <br /> Drainage aggregate type and layer thickness: <br /> Geogrid lengths and elevations: <br /> Compaction methods used: <br /> I hereby certify that,to the best of my knowledge,the work is in conformance with the approved plans <br /> and specifications, manufacturer recommendations and requirements, and/or the applicable <br /> workmanship provisions of the code. <br /> Date <br /> Signature of Person in Responsible Charge <br /> Printed Name/Title/Company <br /> Submit completed form to: Melissa@CriteriumMN.com <br /> Independently Owned and Operated <br /> 161 Dunbar Way/Mahtomedi, MN 55115 <br /> 0: 651.779.7700/criterium-schimnowski.com <br />