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r� <br /> SITE ADDRESS: �. pJ� <br /> '`1 PERMIT#; <br /> Plot Plan: <br /> `7 <br /> GIS Coordinate:Latitude: <br /> Longitude: <br /> I,the Owner/Applicant/Licensed Well Driller/Pump Contractor agrees to indemnify,defend with counsel reasonably approved by County,and hold h <br /> the County and its officers,officials,employees,agents,boards,and commissions(collectively"County")as followarmless <br /> s: <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 Countymay 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> PROPERTY O ER: <br /> SIGN: •Q.J.1L Et" _. <br /> PRINT: 1^) y •� <br /> LICENSED - ELL DRtLLER/�PIJ`Nip CO RACT R: DATE <br /> SIGN: U <br /> DATE <br /> 1. <br /> AUTHORIZATION FOR OTHFR THAN C-57 SIGNING PERMIT APPLICATION <br /> Name of C-37 Licensedhereby authorize <br /> Authorized Representative <br /> Pri <br /> to sign this San Joaquin County Well&Boring Permit Application on my behaX I�understand Usent authorization is valid for one year and <br /> iS limited to the work plan dated on the front page of this application. <br /> EHDO43-06 Ia25rz02l <br /> Pagc 2 of 2 <br /> Well/Pump Permit <br />