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SITE ADDRESS: `�' ' 3 c, W 7 ' PERMIT#: Plot Plan: NU I << v z c � f G P , GIS Coordinate Latitude. _ _ Lonoiiude I,the Owner/Appficant/Licensed Well Or+ller/Pump Contractor agrees to indemnify,deferd with counsel reasonably approved by County,and hold harmless the Canty and its officers,officials,employees,agents,boards,and commissions(collectvely'CounV)as follows: 1. Indemnity. a. From and against any and all cLvrns.demands,actions.proceedings,lawsuits,losses,damages.judgments and/or liabilities arising out of,related to,or in connection with the appl-cation and applied for well or pump or to attack set aide void,or annul,in whole or in part, approval or denial�the applied for permd by the County,and any env,ronmental review documents related to the applied for permit; b. For any and all costs ano expenses incurred by the County on aceaunt of any Claim except where such indemnification is prohibited by law,including bui not t,mited tc damages costs,expenses attorney's fees,or expert witness Costs mat may be asserted oy any person or entity,private ahomey general fees claimed by or awarded to any pany against the County,and the County s costs incurred in preparing an administrative record which are not paid by the petitioner. C. Except as to the County's sole negligence or willful misconduct- 2. Defense 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 obligation to indemnify,defend,and hold harmless the County. b. In the event of a disagreement between County and me regarding defense of any Claim,the County shall have the authority to control the litigation and make litigation decisions,including,but not fin ted to,the manner in which the defense is conducted. If County reasonably determines that having common counse,presents sucn cuunsel with a confect of interest,or if I fad to promptly assume the defense of any Claim u to prompifv emptoy�uunsel reasonably safisfactcry, to the County then. Courcy may utilize the Otfoe df the County Counsel or employ separate outside counsel to represent or defend the County and(shall pav Itu reasonaole artomeys'fees ano costs of sud.'1 co�nsef. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PROPERTY WN9 tS E'O'IR OR WA_T ER E]RRACTION WELL ON PRIVATE ROPERTY): r .i y ZZ Za 2 Stoll: __�_ _ PRINT: ,n"j'}fpWAVis DATE LICCVScDtt--f:uc Uwe-1.' Pt;ym`1Q0nrtuce0R: ` J SIGN: �L l' C7l�sbCx-� --- PRINT: f IDA. `a� j AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION L hereby authorize -N—f(7-57L.c..a AW..—e Repecu a n.,w.mc of Ammn�,e Aeou to sign this San Joaquin County Well&Boring Permit Application on my behalf i understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. ETID043-06 WRrrr2i122 Pftc 2 ort wen r fv,rp P-1