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SITE ADDRESS: PERMIT#: W(ot Plan: of GIS Coordinate:Latitude: Longitude: I,the Owner/Applicant/Licensed Well Driller/Pump Contractor agrees to indemnify,defend with counsel reasonably approved by County, and hold harmless the County and its officers,officials,employees,agents,boards,and commissions(collectively"County")as follows: 1. Indemnity: a. From and against any and all claims,demands,actions,proceedings,lawsuits,losses,damages,judgments and/or liabilities arising 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 part, approval or denial of the applied for permit by the County,and any environmental review documents related to the applied for permit; b. For any and all costs and expenses incurred by the County on account of any Claim,except where such indemnification is prohibited by law,including but not limited to damages,costs,expenses,attorney's fees,or expert witness costs that may be asserted by any person or entity,private attorney general fees claimed by or awarded to any party against the County,and the County's costs incurred in preparing an administrative record which are not paid by the petitioner. C. Except as to the County's sole negligence or willful misconduct. 2. Defense: 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 obligation to indemnify,defend,and hold harmless the County. b. In the event of a disagreement between County and me regarding defense of any Claim,the County shall have the authority to control the litigation and make litigation decisions,including,but not limited to,the manner in which the defense is conducted. 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 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 outside counsel to represent or defend the County,and I shall pay the reasonable attorneys'fees and costs of such counsel. I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PROPERTY OW R: �y SIGN: till PRINT: ;7 / 0 �(��iQJ DATE Z LICENSED /Pum ACTOR: SIGN: PRINT: ///�i�� /6�Q DATE �(-- AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION hereby authorize (Nanw ofC-57 Licensed Authorized Representative) (Print Name of Authorized Agent) to sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. EHD 43-08 WELL DESTRUCTION PERMIT 11/23/21