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SITE ADDRESS: v l�V` 1 �/ �Ju�I V PERMIT#:
<br /> Plot Plan:
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<br /> GfS Coordinate:Latitude: Longitude:
<br /> 1.the Owner/ApplicanbLicensed 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, attomey's fees, or expert witness costs that may be asserted by any
<br /> person or entity,private attomey 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 attomeys'fees and costs of such counsel.
<br /> I HEREBY CERTIFY THAT 1 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 AgTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br /> WORKERS !` SATIO AWS.
<br /> PROPER OWN VUR R UIRED FOR WATER EXTRACTION WELL ON PRIVATERO RTY)'
<br /> SIGN: PRINT: t�� �.rn�� U�SC DATE
<br /> LIFE:\\F: .f: r fC, \rR:\("iOR: \ VV11� (�r 1 7
<br /> SIGN: PRINT:--"dd DATED
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> I, hereby authorize
<br /> !:ume of C'-i%I ti-c,v.l.1u,tarvnl RepraYem�,ive tont Vw,x of:lu,hnnred:1grn1
<br /> to sign this San Joaquin County Well&Boring Pennit Application on my behalf.I understand this authorization is valid li)r one year and
<br /> is limited to the work plan dated on the front page of this application.
<br /> EI ImW?416 au,rmu r„r,,4_
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