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SITE ADDRESS: ZV ly' S C(,� f / PERMIT#: <br /> Plot Plan: <br /> I <br /> GIS Coordinate:Latitude: Longitude: <br /> I,the OwnerlApplicant/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 /> 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 AND WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C SPiT[ON LAWS. <br /> PROPERTY OWI�E IG��T IS RE D FOR WATER EXTRACTION WELL ON PRIV TI€( � <br /> IR RRTt): `Ir\ <br /> n/,,,/JJJ ry)/ j�/��\� ♦4 1 <br /> SIGN: II PRINT: 1 ` �P1yl VLl�W 1 "I DATE �l 1 <br /> LICA.\tiF�1RIL1 F:WU\ C r Z: �'I I�\ <br /> SIGN: 11Jr PRINT'. ,.\ t Vim\ JJJ DATE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, hereby authorize <br /> \ame of('•57lcena4 AWAunzed ReprarnWnvc PnW tia:rc ofAWhir iAgcm <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 /> FHDG43-W"107,2021 Pngc'_u`_ Rd[ Pump Parmn <br />