TO:	BOARD OF SUPERVISORS	WORK AUTHORIZATION TYPE: ST. LUCIE WEST SERVICES DISTRICT	[CHECK APPLICABLE]
450 UTILITY DRIVE	RIGHT-OF-WAY
PORT ST LUCIE, FLORIDA 34986	SURFACE WATER MANAGEMENT IRRIGATION WITHDRAWALS WATER AND SEWER UTILITIES WETLAND MAINTENANCE

1.	PROPOSED USE OF DISTRICT FACILITY:  		
2.	LOCATION OF WORK: SECTION:	 	TOWNSHIP:	 	RANGE:  		
3.	SUBDIVISION:  		LOT:  		BLOCK:   		
DISTRICT WORKS INVOLVED IN PROPOSED CONSTRUCTION OR USE: 		
4.	OWNER OF PROPOSED WORK OR STRUCTURE: 		
STREET ADDRESS / MAILING ADDRESS:  		
	CITY:  		STATE:  		ZIP CODE:  		
5.	APPLICANT OTHER THAN OWNER (IF APPLICABLE):   		
STREET ADDRESS / MAILING ADDRESS:	 		
	CITY:  		STATE:  		ZIP CODE:  		
6.	AREA PROPOSED TO BE SERVED: (Give property description sufficient for identification, including size in acres, and attach survey or property sketch).	

7.	
This application, including sketches, drawings or plans and specifications attached, contains a full and complete description of the work proposed or use desired of the above described facilities of the District and for which authorization is applied, and it shall be part of any authorization that may be issued. The applicant agrees that all work or the use of the District's facilities involved shall be in accordance with the approved authorization and with the Policies and Procedures Manual of the District. The applicant has examined the manual as the same may be hereafter from time to time amended, changed, or revised and
understand that such manual shall be incorporated by reference as a part of any work authorization may be approved by the District.	

SPECIAL CONDITIONS ARE AS FOLLOWS:

In the event the ST. LUCIE WEST SERVICES DISTRICT wishes to obtain ingress or egress to its easement and/or right-of-way for the purpose of maintenance of District works, the removal and reinstallation of any construction permitted hereunder shall be at owner's expense.

In undertaking any of the activities contemplated by this work authorization, the applicant hereby agrees to comply with all federal, state, and local statutes, laws, rules, and regulations governing such activities, including but not limited to water quality standards for off-site discharges; and to abide by all terms and conditions of any permit or other approval issued by any agency exercising regulatory jurisdiction over such activities.

The applicant, by accepting of the work authorization, covenants and agrees that the ST. LUCIE WEST SERVICES DISTRICT shall be promptly indemnified, defended, protected, exonerated, and saved harmless by the applicant from and against all expenses, liabilities, claims, demands and proceedings, including reasonable attorney's fees in defense of such matters, incurred by or imposed on said District in connection with any claim proceeding, demand, administrative hearing, suit, appellate proceeding, or other activity, including unfounded or "nuisance" claims, in which the District may become involved, or any settlement thereof, arising out of any operations under this work authorization, including but not limited to use of canal water for irrigation purposes; damage to landscaping; paint damage to automobiles, buildings, or other structures; liability for charges, fees, assessments, fines, and penalties levied by any agency exercising regulatory jurisdiction over any of the activities contemplated by this work authorization; and any property damage or personal injuries, fatal or non-fatal, of any kind or character. The applicant further agrees that any such expense so incurred by the District may be recovered by the District through offset against any claim for reimbursement or other charge that the applicant may assert as due from the District. If any such expense so incurred by the District is not paid upon demand and is placed in the hands of an attorney for collection by suit or otherwise, the applicant hereby agrees to pay all costs of collection and litigation, including, but not limited to reasonable attorney's fees.

By undertaking the construction allowed under this Work Authorization, the Applicant agrees and understands that it is solely responsible for, and shall indemnify and hold the District harmless from, (1) any and all restoration of District owned or controlled properties and facilities required as a result of such construction, and (2) any and all claims of third parties who currently have facilities located in District owned or controlled property and which facilities are damaged as a result of such construction.

Submitted this	day of	,	 COMPANY AND/OR OWNER:   		
BY:   	

NAME:	TITLE:   	

ST LUCIE WEST SERVICES DISTRICT:	ST LUCIE WEST SERVICES DISTRICT:

Public Works Director	Utilities Director

ENGINEERING:	BOARD OF SUPERVISORS:

CHECKED AND APPROVED BY	REVIEWED AND APPROVED AT BOARD MEETING INFRASTRUCTURE SOLUTION SERVICES
DISTRICT ENGINEERS			HELD	, 20 	 BY:	DATE