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SITE ADDRESS:. �'�3� 5 •gULwoDD PERMIT#:
<br /> Plot Plan:
<br /> or I
<br /> GIS Coordinate,Latitude: Longitude:
<br /> I,the OwnedApplicant/t:tcensed Well Driller/Pump Contractor agrees to indemnify,defend with counsel reasonably approved by County,and hold harmless
<br /> the County and.kofficers,officials,employees,agents,boards,and commissions(collectively`County')as follows:
<br /> 1. Indemnity:
<br /> a.
<br /> -;Flom and against any and all Balms,demands,actions,proceedings,lawsuits,losses,damages,Judgments and/or Itablltties 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 /> For any and all costs and expenses incurred by the County on account of any Claim,except where such Indemnification is prohlbRed by
<br /> law;including but not limited to damages,costs,expenses,attorneys fees,or expert witness costs that may be asserted by any person
<br /> of 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 Countys sole negligence or wiitful miscanduct.
<br /> 2. ;DefThe eirseCor
<br /> <a'.�� unty may participate or direct the defense of any Clalm.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 arty Claim,the County shall have the authority to control
<br /> the litigation and make litigation decisions,Including,but 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 satilsfacfary to the County,then County may Lrdltze the Office of the County Counsel or employ separate
<br /> outside counsel:to represent or defend the County,and I shall pay,the reasonable attomeys'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 JOAQUIN
<br /> COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND
<br /> ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS
<br /> COMPENSATION LAWS.
<br /> PRO,PERTY OWNER: 0
<br /> SIGN: PRINT: CSU e'er �C/^C� DATE I/-")g
<br /> TJCENSp CONTRACTOR_ .
<br /> SIGN; PR1N7-,�/`.� �/��(Ip/� DATE
<br /> -•AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> I hereby authorize
<br /> (L7emc oTGS7 Llccmcd Authatttd xcp ve) (Pmt NasoarA,ahor}mi Apm)
<br /> to sign this Safi.Joaquin County Well&Boring Permit Application on my behalf.I understand this authorisation is valid for one year and
<br /> is limited to the.Wok.plan dated on the front page of this application.
<br /> EHD 43-08 WELL DESTRUCTION PERMIT
<br /> tt123721
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