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SITE ADDRESS: _ PERMIT#:
<br />Plot Plan:
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<br />! I, the Owner/ApplicantlLicensed 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, boares, 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 />E part, approval or denial of the applied for permit by the County, and any environmental review documents related to the applied for
<br />VV permit;
<br />' b. For any and all costs and expenses incurred by the County on account of any Claim, except where such indemnification !s prohibited
<br />by law, including but not limited to damages, costs, expenses, attorney's fees, or expert witness costs that may be asserted by ary
<br />person or entity, private attorney general fees claimed by or awarded to any oarty 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 :he County's sale 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 deferse of any claim shall not relieve me of any
<br />obligation to indemnify, defend, and hold harmless the County.
<br />b. In the event o` 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 manna• 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 LAW,",D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS
<br />CURRENT AND ACTIVE WITH THE CALIFORNIAC/¢NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br />WORKERS COMPENSATION LAWS.
<br />PHOPERTY OWNER: --\
<br />SIGN:
<br />I mI:: \
<br />SIGN:
<br />%( TOR:
<br />PRINT: DATE
<br />Ar '
<br />PRINT:d'/ "1. /eI___ DATE
<br />A TI ORIZATI07-FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br />1. _ ...__._._. , hereby authorize
<br />Nwuc of C.til Liww-d Mlhnrind Rynccntotivc Print Nna¢ of MOM -1 Agent
<br />to sign this San JOagUilt COLIBLy WCII & (Boma 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 />hR 04.1- G nY25202l P.:, e -',I , %%0t I P," 1, Dec nil
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