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1350 Rest Point Circle, Mound, Minnesota <br />June 9, 2022 (Rev. June 16, 2022) <br />Page | 4  <br />  <br />Statement of Conformance  <br />(for Retaining Wall Contractor)  <br />  <br />  <br />Project Name/Address:  _____________________________________  <br />  <br />   _____________________________________  <br />  <br />   _____________________________________  <br />  <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 />  <br />_____ Block type: _____________________________________________________________________  <br />  <br />_____ Geogrid type: ___________________________________________________________________  <br />  <br />_____ Description of site soils (i.e. sand, clay, loam): _________________________________________  <br />  <br />_____ Leveling pad size and type of material: _______________________________________________  <br />  <br />_____ Embedment depth (courses of block buried): _________________________________________  <br />  <br />_____ Draintile type and diameter: _______________________________________________________  <br />  <br />_____ Drainage aggregate type and layer thickness: _________________________________________  <br />  <br />_____ Geogrid lengths and elevations: ____________________________________________________  <br />  <br />______________________________________________________________________________  <br />  <br />______________________________________________________________________________  <br />   <br />Compaction methods used: _______________________________________________________  <br />  <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 />  <br />______________________________________________ Date ____________________________  <br />Signature of Person in Responsible Charge  <br />  <br />_____________________________________________________________________________________  <br />Printed Name/Title/Company  <br />  <br />Submit completed form to: Melissa@CriteriumMN.com