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SITE ADDRESS: lVi S�j I i` �G� V PERMIT <br /> Plot Plan: <br /> AA <br /> 1 101, <br /> k I <br /> GIS Coordinate:Latitude: Longitude: ✓ <br /> I.the Owner/ApplicantlLicensed 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 /> n 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 /> 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 ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS MPENSATION LAWS. <br /> PROPERTY O ( N TURE REQUIRE FOR WATER EXTRACTION WELL ON PRIVATE PROP RT(Y <br /> SIGN: PRINT: ttt f� Iµ eS I DATE <br /> tICFN$ED LLF ` CU\IK\l 10)K' IVI'/I �II� O� ISD <br /> SIGN: PRINT: "1 .••!/// DATE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize <br /> tiarR ofC-57 L---d.4utlw�rve,l ItePrr.emsu��e Pr mt \ern: <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 /> f I IIX;J3_ro�tN U'_U`= P,'2,*_ Urll Pum K—W <br />