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SITE ADDRESS: C�C� } L U C t� S F, PERMIT#:
<br /> Plot Plan: L.v C L., S
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<br /> GIS rdinate: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 andlor 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,casts,exPenses,attorney's fees,or expert witness casts that may be asserted try 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 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 attomeys'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 UCENSE IS
<br /> CURRENT AND ACTTWWLTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL
<br /> WORKERS_COJiSr MPEA/nON LAWS.
<br /> PROPERTY t 1-#R.(8rclrywr URE IS REQUIRED FOR WATER EXTRACTION WELL ON PRIVATE PROPERTY):
<br /> SIGN: -- ,/, [
<br /> Pwrrr: DATE
<br /> LICE.VSFDi'ELJyyL 'l�1yP�CONTAACTUR:
<br /> SIGN: /` l Cc�AC�� Pltnrr. 1t-r N C�'r S CYl DATE
<br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION
<br /> 1, hereby authorize
<br /> fame M C-57 L--d And.-d Rey'orntarz P4 Nam of AmA,r=d A#—
<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 /> Fnna�-fw an�r o>, Np Z on w01,"P-1
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