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SITEADDRESS: 4001 N Duncan Rd Linden,CA 95236 PERMIT#: <br />Plot Plan: <br />I I I I I I I I I I I I I <br />- I � <br />II II I 1 IIIA <br />II II I II I i i <br />II I I I II. II <br />fll I I! I Il II I I111M <br />III L I I 1 11 IIIA II IIIllll <br />-i <br />I I I I 1 ! <br />II II III I i� I I II <br />L14 <br />li I II I III I iI <br />II4 IT II i i I 1 1111 11 <br />III A <br />IItHEI, <br />GIS Coordinate: Latitude: Longitude: <br />I, the Owner/Applicant/Licensed Well Drilfer/Pump Contractor agrees to indemnity, 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 />Indemnity: <br />a. From and against any and all 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 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 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 />SIGN: <br />PRINT: <br />DA <br />LICEN $'ELL D-R/PUNIP CONTRACTOR: <br />SIGPRINT: DATE 7 Gd <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize <br />Name orC-1 , Licensed Authorized Representative Print Name of Authorized Agent <br />to sign this San Joaquin County 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 />ERD043-06 10,'2J3021 Pace 2 of? Well: Pump Pccmit <br />