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h SITE ADDRESS: 1 n j EL D a R A D b �� S Tc k 7-0 FJ (A _ PERMrr#: Plot Plan: -------------- --------------- -—————————T#——————— ———— — ---------- —M GIS Coordinate:Laliluda: lnnglttldo: I,the OwnerlAppllcantlLicensed Well Driller/Pump Contractor agrees to IndomNfy.defend with counsel reasonably approved by County,and hold harmless the County and its officers,officials,employees,agents,hoards,and commissions(coil ectivety'County")as follows: 1. Indemnity' ties a. From and against any and all claims,demands,actions,proceedings,lawsuits,losses.damages, judgasidementsvoidor /or liabiliwhobrisi in out of,related to,or in connoatlon with the application and appiied for well or pump or part.approval or denial of the applied for peril by the County,and any environmental review documents related to the applied for permit; b. For any and all costs and expenses Inciirreil by the County on account of any Claim,except where such Indemnification Is proNblled by law,Includmg but not Ilmiled to darnagOS,costs,expenses,anomays feels,or expert Cosst�ts t the Couat may nty's asserted ertedcosts rby any person or entity,privele attorney general fees claimed by o`awarded aneon any party again st the red In preparing an administrative record which aro not paid by C. Except as to the County's sole negligence or willful misconduct. 2. Defense; a. The County may participate or direct the defense of any Claim.The County's actions M defense of any claim shalt not rallave me of any obligation to indemnify,defend,and hold harrntasc the County. b. In the event or a disagreement between County and me regarding defense of Orly Claim,the County shall have the authority to control the litigation and make litigation decisions.Including.but not Ilmited to,the manner In which the defense Is conducted. II County feasnnabty determines that laving common counsel presents such Counsel with a conflict of Interest,or If I Jett to promptly assume the defense of any Claim or to promptly employ counsel reasonably satisfactory to the County,hien County may utUlze [he Office of the County Counsel or employ separate outside counsel to ropresonl or defend the County,and I shall pay the reasonable attorneys'fnos and costs of such counsel. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN CO TY ORDINANCES, STATE LAWS, AND RULES AND REOULATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT ACTIVE WITH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKER PENSATION S. PROPERTY0 ER: fit ,<..lJr► DATE PR1N1: SIGN: / LICA e L DRII.LY UU6C CTO DATE e� IQ LbZ C✓ SION: PRINT: t UTEIO IZA ION FOR OTHER THAN C-57 GNNU(��jERMITAPPLICATION hereby authorize R 0 GK- G��'�P�F t L — —.--- I, ntnr Nur or AMtrxbcd As.w enc ofC•17 lknsd uMonwd RtN�rsrh.�w+ to sign this San Joaquin County Well&Boring Permit Application on my behalf I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. hit.3 d 7 wail/Pwry Pa ed r:uunn 06 10(21/2021