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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 />O: 651.779.7700 / criterium-schimnowski.com <br />a