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SITE ADDRESS: 7gp sG1�f�L l� 4=N PERMIT#: AI( OC1Q,el
<br /> Plot Plan:
<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 out
<br /> 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 part,
<br /> approval or denial of the applied for permit by the County,and any environmental review documents related to the applied for 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 by
<br /> law,including but not limited to damages,costs,expenses,attorney's fees,or expert witness costs that may be asserted by any person
<br /> or entity,private attorney general fees claimed by or awarded to any party against the County,and the County's costs incurred in preparing
<br /> 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 separate
<br /> outside counsel to represent or defend the County,and I shall pay the reasonable attomeys'fees and costs of such counsel.
<br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN
<br /> COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND
<br /> ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS
<br /> COMPENSATION LAWS.
<br /> PROPERTY OWNER:
<br /> SIGN: PRINT: DATE
<br /> LICENSED F,I,I.11 I,E P'M CONTR.4('T(lR: ���)
<br /> SIGN: , PRINT: Ii� tXYV4� DATE
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> I, hereby authorize
<br /> (Name of C-57 Licensed Authorized Rcpmxentatirc) (Print Name of Amhorvocl 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 /> EHD 43-08 WELL DESTRUCTION PERMIT
<br /> 11/23/21
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