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SITE ADDRESS: `� I w H W 7 I-D PERMIT Plot Plan: t� U I I , I r I I � i I fi F�T 1 E GIS Coordinate Latitude. _ Lonoitude _. I,the Owner/Applicant/Licensed Well OrUler/Pump Contractor agrees to indemnify,defend with counsel reasonably approved by County,and hold harmless the County and its otfrcarz,officials,employees,agents,boards,and commissions(collectively'CounV)as follows' 1. Indemnity. a. From and against any and all claims, demands,actions,proceedings,lawsuits,losses,damages.judgments and/or liabilities arising 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 pan, approval or denial cl. the applied for pemrd Iry the County,and any ervnronmentaf review documents related to the applied for permit; b. For any and all costs and expenses incurred by thu County on account of anv Cla:m except where such indemnification Is prohibited by taw,including bio not lmited to damages costs,expenses.attorney's fees,or expert witnass mats Milt may De assorted oy any persrm or entity,private attorney general fees claimed by or awarded to arty pang 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 Countys 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 shelf have the authority to control the litigation and make litigation decisions,including,but not limited to,the manner in which the defense is conducted. If County reasonably determines that having common cuurtse:presents sucn ctwnwl with a conflict of Interest,or N 1 fail to promptly assume the defense of any Claim u to promptly employ:uumef reasonably satisfactory to the County thee, County may utilize the Office gf Itle County Counsel Or employ separare outside cuumet to represent or defend the County and I shall pay the reasonaole atiomeys'fees and costs of sucn counsel. 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. PROPERTY JNF Is �OS IR OR WATER OnRACTION WELL ON PRIVATE ROPEAT Y): _ SIGN:_ / _ ._. PRINT: � U-d� 4 2 Z 2 G LICExscD H ELL.UW rumrQONTRACTOR: SIGN: f-'.[;-fd��./�fCs^ PLANT:�,) 1A tI DATE -7__L..._ AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION [, hereby authorize ... _.. 'N or47-57 Limited Amlbnad It pre%un•a Prim Name of AWtnr i at Age _ 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. EIM043-6 Oart17R 2 Mn=of 2 W dl Puny Pmnr