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Nov 1 62023 1:41 pm 1 SITE ADDRESS: PERMIT#: Plot Plan: WI I 1 � i 1 I i I I I I I 1 I i i I I i 1 I I I I I I i l I I ' l Ili I Ill 1 I I I I 1 1 ETTT I I 7 I i G15 CoorcJtnete:latitude Longitude: L�'K ii I,the Om%er1App6cerV1Jcensed Weli DdllerlPurrip Contractor agrees to indemnify,defend with counsel reasonably approved by Coun y,and hold hamiess the County and its officers,officials,employees,agents,boards,and Commissions(oollecdvaly County')as follows: 1. Indemnity, a. From and against any and aN claims, demands, actions,proceedings, lawsuits, losses,damages,judgments ardlor liabilities adsfng out of,related to,or in connection with lie application and applied for well or pump or to attack,set aside,void,or annul.in wide or in perL approval or denial of the applied for permit by the County, end any environmental review documeNs related to the applied for permit; b. For any and all casts and expenses incurred by the County on account of any Clsin,e=eot where such indemrUficallon is prohibited by lave, including but not lirrAed to damages,costs,expenses,attcmey's fees, or expert witness casts that NOV be esseRed by any person or entity,private attorney general fees claimed by or awarded to any party against the County,and the Courty's costs incurred in preparing an a rniriairzfive record which are not paid by the petitioner. C. Except as to the County's sole negligence cr willful misconduct a. fie County may pltlticipale or direct the defense of any Clevn.The County s actions In defense of any Balm steal not relieve me of any obligaflon to indemnify,defend,and hold harrTaeas that County- b. In fhe event of a d sagreenwu between County and me regarding defense of any Clalm,the County sheN have the authority to ccrltrei the fltlga9on and make Iltlgallon decisions,including,but not limited to,the manner in which the defense is conducted. If County reasonebly detetmines that having common counsel presents such counsel with a corif ck of lntaast or if 1 fail to promptly assume the defense of any Calm or to promptly empty counsel reasonably satisfactory to the County, Lien County may utfto the Offtce of the County Counsei or employ separate outside counsel to represent or defend the County,and I shall pay the reasonable attorneys'fees and costs of such counsel. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE CAUFORNtA CONTRACTORS STATE LICENSE BOARD AND THAT f AM IN COMPLIANCE WITH ALL WORKERS COMPENSATfON LAWS. f oW'7EXT era 1 PRINT ti� Ii /� I.,c QtC SIGN: PRINT: l _ DA-1- A=ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, .hereby authorize Nut arCS7 Ua=xd AmmdaA AcRaew6- PAW A'mG afAlIbMUM A:= to sign this San Joaquin County Well&BC&V PMtnit Application on my behalf I understand t1lis authorization:is valid for one year and is iim. ted to the work plan dated on the front page of this aapliearion.