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SITE ADDRESS: hu" L I&, (j�.Sei OLIJ PERMIT Plot Plan: iMEN MEN IN MENMOMMMIMMEMMEMEMME ON No MEN ON 0 MEMOMMOMMEMEMMOMMEMMMEMMIMMEMEME 00 ■MEMMMEMM MEEMEMPAN M MISENMOMMEMEMEMlop No Z 1521111 14PPIAMEMMOMEMEMINNMiM PEMMMOMME MEMMM11611owbi WIN! Novi," "MA one MMMMMMMMMMMMMEIMMOMI ONO MEN MIMMIMEMMEMMOMMON ME MOMME MEMO MM M NEON ME -MME MEMO MMEM MOOMMOMMEME Indemnitv. 3. From and against any and all claims, demands, actions, proceedings, lawsuits, losses, damages, judgments and/or liabilities ansing out of, related to, or in connection with the application and applied for well or pump or to attack, set aside, void, or annul, In whole or n part, approval or denial of the applied for permit by the County, and any environmental review documents related to the appiwal for permit; b. For any and all costs and expenses incurred by the County on account of any Claim except where such indemnification is prohibited by law, including but not limited to damages, costs, expenses, attorney's fees, or expert witness costs that may be asserted by any person or entity, private attorney general fees claimed by or awarded to any party against the County, and the County's costs Incurred In preparing an administrative record which are not paid by the petitione- C. Except as to the County's sole negligence or willful misconduct Z. nefense a. The County may participate or direct the defense of any Claim The County s actions in defense of any claim shall not relieve me of any obligation to Indemnify, defend, and hold harmless the County. b. In the event of a dlsagreemenl between County and me regarding defense of any Claim. the County shall have the authority to control the litigation and make litigation decisions, including, but not limited to, the manner in which the defense Is conducted 11, County reasonably detem)Ines that having common counsel presents such counsel with a conflict of interest, or if I fail to promptly assume the defense of any Claim or to promptly employ counsel reasonably satisfactory to the County, then County may utilize the Office of the County Counsel or employ separate outside counsel to represent or defend the County and I shall pay the reasonable attorneys fees 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 COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PROPERTY OWNER: d <J LL SIGN' %r ' / C 7 PRINT: �� _ rr t DATE LicF\sEui51 F U I II' CONTRACTOR: ,, SIGN: PRINT: &40 DATE \Z\�3`7,71 ATJTHORIZ.ATION FOR OTHER THAN C-57 SIGNING; PERMIT APPLICATION I. , hereby authorize 'Jain of C.37 i.icemed Aui honied Rque—mao'e Pnu; V;, me of Aoihn ved ,igcn to sign this San Joaquin County Well & Boring Permit Application on my behalf. 1 understand this authorization is valid for one year and is limited to the wort: plan dated on the front page of this application. EHDC43-06 IC252021 Tape or? Re!. -Pump P—r