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DocuSjgn Envelope ID: C620F69E-ECD2-4050-BB49-C4AB63D3E119
<br />SITE ADDRESS: q o S -F�Jz�cwotd P dot! PERMIT #:
<br />Plot Plan:
<br />VIS coordinate: Latitude: Longitude:
<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
<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 />1 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 />i �--Signed by;
<br />PROP RTY OWNER:
<br />1fU AA/,V, Amaninder 5 Mann 3/7/2022
<br />SIGN: (/�88 � S ' "`�'^^�`^�`� PRINT: DATE
<br />LICENSED W71, PUMP CONTRACTOR: j///'''���� (jjJJJjjj ,,, J�
<br />SIGN: V J \_/'��. PRINT:0J Vu(+J c —h �V DATE v
<br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br />I, , hereby authorize
<br />Name of G57 L.icensod Authorized Representative Print Nave 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 />EHDO43-06 10/25/2021 Pagc 2 of 2 Well / Pump Permit
<br />
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