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1350 Rest Point Circle, Mound, Minnesota <br />June 9, 2022 (Rev. June 16, 2022) <br />Page | 4 <br /> <br />StatementofConformance <br />(forRetainingWallContractor) <br /> <br /> <br />ProjectName/Address:_____________________________________ <br /> <br />_____________________________________ <br /> <br />_____________________________________ <br /> <br />Formtobesubmittedwithallconstructionprogressphotosbytheretainingwallcontractorattimeof <br />wallcompletion.ThisformisrequiredinordertorequestawallcompletionletterfromCSE: <br /> <br />_____Blocktype:_____________________________________________________________________ <br /> <br />_____Geogridtype:___________________________________________________________________ <br /> <br />_____Descriptionofsitesoils(i.e.sand,clay,loam):_________________________________________ <br /> <br />_____Levelingpadsizeandtypeofmaterial:_______________________________________________ <br /> <br />_____Embedmentdepth(coursesofblockburied):_________________________________________ <br /> <br />_____Draintiletypeanddiameter:_______________________________________________________ <br /> <br />_____Drainageaggregatetypeandlayerthickness:_________________________________________ <br /> <br />_____Geogridlengthsandelevations:____________________________________________________ <br /> <br />______________________________________________________________________________ <br /> <br />______________________________________________________________________________ <br /> <br />Compactionmethodsused:_______________________________________________________ <br /> <br />Iherebycertifythat,tothebestofmyknowledge,theworkisinconformancewiththeapprovedplans <br />andspecifications,manufacturerrecommendationsandrequirements,and/ortheapplicable <br />workmanshipprovisionsofthecode. <br /> <br />______________________________________________Date____________________________ <br />SignatureofPersoninResponsibleCharge <br /> <br />_____________________________________________________________________________________ <br />PrintedName/Title/Company <br /> <br />Submitcompletedformto:Melissa@CriteriumMN.com