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SITE ADDRESS: ( 3 o C. Vf L l ", X )z DI Lob 110 %A ; q,5)- � 0 PERMIT #:_ W 604,
<br />"
<br />Plot Plan:
<br />I, the Owner/Applicant/Licensed Well Driller/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 at claims, demands, actions, proceedings, lawsuits, losses, damages, judgments and/or liabilities arising
<br />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 in
<br />part, approval or denial of the applied for permit by the County, and any environmental review documents related to the applied for
<br />permit:
<br />b. For any and all costs and expenses incurred by the County on account of any Claim, except where such Indemnification Is prohibited
<br />by law, including but not limited to damages, costs, expenses, attorney's fees, or expert witness costs that may be asserted by any
<br />person or entity, private attorney general fees claimed by or awarded to any party against the County, and the County's costs incurred
<br />in preparing an administrative record which are not paid by the petitioner.
<br />c. Except as to the County's sole negligence or willful misconduct.
<br />2. Defense:
<br />a. The County may participate or direct the defense of any Claim. The Countys 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 County reasonably determines that having common counsel presents such counsel with a conflict of interest, or if I fail to promptly assume the defense of
<br />any Claim or to promptly employ counsel reasonably satisfactory to the County, then County may utilize the Office of the County Counsel or employ
<br />separate outside counsel to represent or defend the County, and I shall pay the reasonable attorneys' fees and costs of such counsel.
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN
<br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS
<br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br />WORKERS COMPENSATION LAWS
<br />\ PROPERTY OWNER'
<br />y SIGN: ' L`*�L —�'1� PRINT: NITh4/ &f y)---, DATE •% / /-Z�
<br />LICENSED
<br />WE l2JLLEWPUMi' O CfOR: f�
<br />SIGN: PRINT: ie--LIQ{�n ►� �Z DATE 2Z
<br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br />, hereby authorize _
<br />Name of C-57 Lwonsed Authorized Representative Print Name of Aulhor¢ed Agunt
<br />to sign this San Joaquin Comity Well & Boring Permit Application on my behalf. 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 />MID1143-0e ionsl2o2i Page 2 oft Well I Pungs Pernui
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