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SITE ADDRESS: 110150 LO ne 1 r c e _ _ PERMIT #F P — 2— I 0 -Zq Z
<br />DIM Clan•
<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, aid commissions (collectively "County") as fnllnws:
<br />1. Indemnity:
<br />a. From and against any and ail claims, demards, actions, proceedings, lawsuits, losses, damages, judgments andlor liabilities arising
<br />out of, related to, or in connection with the application and applied for well or pump or to attack, set aside, voic, 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 exper, witness costs that may be asserted by any
<br />person or enlity, 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 actinns 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 regard ng defense of any Claim, the County shall have the authority to control
<br />the litigation and make litigation decisions, including, but not lim,ted to, the manner in which the defense is conducted.
<br />It 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 Courtly, then County may utilize the Cffice 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 O E : — /—
<br />SIGN: PRINT: L
<br />.ff /J:M �L �iEJ DATE '7 Z
<br />LICEN$en VGI,L DRILLER/RIP CONTRACTOR: _ /
<br />SIGN: E PRINT: cl A PN 61 4 DATE 31,41ZD
<br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br />I, , hereby authorize
<br />Nn rte ofC-57 Lie.nsed Authmiud Rcprescntntive Print Namcof 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 />ElID04;-06 I Ons/ID2 Page 2 of 2 Well / Pwnp Terni(
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