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SITE ADDRESS: l� / �� ; PERMIT#:
<br /> Plot Plan:
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<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
<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 1 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'Tees 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 I AM IN COMPLIANCE WITH ALL
<br /> WORKERS COMPENSATION LAWS.
<br /> PROPERTY OWNER:
<br /> SIGN: PRINT: DATE
<br /> LCEN�� VELL DRILLER/PUN LlCONTRACT/ORi2;
<br /> SIGN:
<br /> L, PRINT:1
<br /> I0-O DATE
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> I, ,hereby authorize
<br /> Nance orCS7 Licensed Authorized Representative Print Nome of Autlmn7sd Agem
<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 /> E11130-3 06 1&25;1021 Page 2 oF?
<br /> Well/Pump Pernut
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