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SITE ADDRESS: a2L,_\',0 qLCW -1;_m_e_�;Iq(PERMIT#:
<br /> Plot Plan:
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<br /> FT T
<br /> GIS Coordinate:Latitude- Longitude:
<br /> 1,the Owner;Applicant/Licenbed Well Driller,'Pwnp Contractor agrees to indemnify,defend%vith 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 /> i. Indemnity:
<br /> a. From and against any and all claims, demands,actions, proceedings, lawsuiI5, 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 apotLcl for permit by the County, and any environmental review documents related to the applied for
<br /> permit;
<br /> b. For any and all r-,)st:ane expenses incurred by the County on account of any Claim,except whLm such indemnification is prohibited
<br /> by law, including but not tirntod to damages,costs, expenses, attomey's fees,or expert witness costs that may be asserted by any
<br /> person a,entity,private attorney general fees mimed by or awarded to any party against,the Counly,ar.d the county's costs incurred
<br /> in preparing an administralive record Wiich are not paid by the petitioner.
<br /> c. Except as to the County's sole negligence or vA!Ifu;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 indernmfy,defend,and hold harmtess the County.
<br /> b. In the event of a d,sagreennent between County and me regarding defense of any Claim,the County shalt have the authority In 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 cr3unsel with a conflict of interest,or if I fail to promptly assume tno defense of
<br /> any Claim or to prompiy employ counsel reasonably satisfactory to the County, there County may utilize the Of5ce of the County Counsel or employ
<br /> separate outside counsel to represent or defend the County,and I shall pay the reasonable attomeys'tees 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 COMPENSATION LAWS.
<br /> PROPERTY OWNER(SIGNATURE IS REQUIRED FOR WATER F ACTION WELL ON PRIVATE PROPERTY):
<br /> SIGN: PRINT; DATE
<br /> PRINT: DATE
<br /> SIGN!
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> hereby authorize
<br /> P,uv Na ofAvIN,1✓ad,%gl
<br /> to sign this San Joaquin County Welll& Boring Permit Application on mv,behalf. I understand this authorization is valid for one year and
<br /> is limited to the work plan dated on the tient page of this application.
<br /> haD043-OrAV"02022 V,C";P� ,P:r
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