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T � SITE ADDRESS: % / a PERMIT#: Plot Plan: LL I 1111 I II I I I I I 1111111 It \All -------U II 11111111 II I II III 111111 II II ! . . l IIIIIIII II I IIII 1i fl ! Ili I LU I IIII I 1 I III ! FiHAT-1 I II II 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 Countys 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 attomeys'fees and costs of such counsel. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS_ 1 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 COMPENSATI LAWS. PROPERTY OWNER(SIGN U IS REQUIRE4+411 WATER EXTRACTION WELL ON PRIVATE PROP R ) SIGN: �� PRINT: ( '�,� DATE `J 1 U LICENSED WELL DRI R/Pul"tP TOR: t SIGN: Al PRINT: I� l C �'� DATE O --2 -22 A HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, hereby authorize Naiw of C-57 Licensed Authorvxd 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 near and is limited to the work plan dated on the front page of this application. Euotu3-oe 04/07/-02-1 Parc 2 ora Vedl:Rum Pom.