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S;TE ADDRESS; PERMIT #:
<br />Plot Plan:
<br />ON 11 ME=
<br />NNE 0 19.r.
<br />No M MEN Ill... 0 11011N 0100011
<br />I M I 011MMEM 0 1 E I MEN
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<br />0 MINNIE EMEMEMEMEMMOMMEME 00 0
<br />110 MEN MMMMMEMMMMMMMMMMMN IIMM
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<br />I, the Owner/Applicanl/Liconsed Well Ddller(Pump Contractor agrees to Indemnify, defend with counsel reasonably approved by County, and hold harmless
<br />the County and Its officers, officials, employees, agents, boards, and commissions (collectively `County") as follows:
<br />1. Indemnity.
<br />a. From and against any and all claims, demands, actions, proceedings, lawsuits, losses, damages, judgments and/or liabilities arising out
<br />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 in part,
<br />approval or denial of the applied for permit by the County, and any environmental review documents related to the applied for permit;
<br />b. For any and all costs and expenses incurred by the County on account of any Claim, except where such Indemnification Is prohlblted by
<br />law, including but not limited to damages, costs, expenses, attorney's fees, or expert witness costs that may be asserted by any person
<br />or entity, private attorney general fees claimed by orawarded to any partyagainst the County, and the County's costs Incurred In preparing
<br />an administrative record which are not paid by the petilloner.
<br />c. Except as to the County's sole negllgence or willful misconduct
<br />2. Defense:
<br />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
<br />�. obligation to Indemnify, defend, and hold harmless the County.
<br />.—� b. in the event of a disagreement between County and me regarding defense of any Claim, the County shall have the authority to control
<br />the litigation and make litigation decisions, Including, but not limited to, the manner In which the defense is conducted.
<br />If dnt easonabiy determines that having common counsel presents such counsel with a conflict of Interest, or if I fail to promptly assume the defense of
<br />an Clai r to promptly employ counsel reasonably satisfactory to the County, then County may utilize the Office of the County Counsel or employ separate
<br />out nsel to represent or defend the County, and I shall pay the reasonable attomeys' fees and costs of such counsel.
<br />I HE Y ERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTH SAN JOAQUIN
<br />COU O DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND
<br />ACTT TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS
<br />COMPEN ATION LAW C—
<br />PROPERTYOWNER; �--� , r
<br />SIGN; PRINT:
<br />Y e^ IVS DATE O l Z"`„_
<br />LICENSED WELL DRILLER/PUN? CONTRACTOR:
<br />SIGN
<br />PRINT: DATE
<br />AUTHORIZATION FOR OTHER'11 IAN C-57 SIGNING PERMIT APPLICATION
<br />, hereby authorize
<br />IN— orC-17 L :aa. -d Awhon,.d R4-081i�e) (Prim Name of Aldlomed Agnu)
<br />to sign this San Joaquin County Well & Boring Permit Application on my hehalf. I understand this authorization is valid for one year and
<br />is limited to the work plan dated on the front page of this application.
<br />EHD 43-08 WELL DESTRUCTION PERMIT
<br />11/23121
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