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SITE ADDRESS: t/�'{U�1 1 ti t/Vt1O ►�V f `(/V PERMIT#: <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 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 Clain, except where such indemnification is prohibited 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 or awarded to any party against the County, and the County's costs incurred in preparing <br />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 separate <br />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 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND <br />ACTIVE WITH THE CALIFORNI ONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS <br />COMPENSATION LA#,� n n I fl C <br />PROPERTr OWNER:VORV hj"M� j/', 5 f� 7' <br />SIGN: PRINT: S/ ' 1 Y DATE <br />LICENSED W DRIL R/ i C <br />SIGN: PRINT Y1 JC 1 i I I C DATE O ✓ ' OI '�� <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize <br />(N.= orC-57 Licemed Authorvnd Represer"ive) (Print Nurrc of Authorized Agmt) <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 />EHD43-08 WELL DESTRUCTION PERMIT <br />11/23!21 <br />