|
t
<br /> SITE ADDRESS: PERMIT#:
<br /> Plot Plan:
<br /> It
<br /> -' I 1 1,
<br /> GIS Coordinate: Latitude: Longitude:
<br /> I,the Owner/Applicant/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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br /> WORKERS CO PENSATION LAWS.
<br /> PR0PERT ERP, 111N A T U IRED FOR WATER EXTRACTION WELL ON PRIVATE PROP RT''I,` �y ,
<br /> SIGN: 'tii PRINT: t^�/16�I '^�" �Y�/V" ' DATE J Zv ZL
<br /> LICENSEDW, L 1 ER/PlMP C TRACTOR:
<br /> SIGN: 04PRINTI" U V CJ'�1 I 1 y DATE v (
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> 1, hereby authorize
<br /> Name of CS7 Licensed Authorized Representative Pnnt Name of Authorized Agent
<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 /> EHD043-00 04/07/2022 Page'_of 2 Well/Pump Permit
<br />
|