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2525 Dunwoody Avenue, Wayzata, Minnesota <br />February 9, 2024 <br />Page | 4 <br />Statement of Conformance <br />(for Retaining Wall Contractor) <br />Project Name/Address: _____________________________________ <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 />_____ 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 />______________________________________________________________________________ <br />______________________________________________________________________________ <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 />_____________________________________________________________________________________ <br />Printed Name/Title/Company <br />Submit completed form to: Melissa@CriteriumMN.com