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Date I'v'I a terial Amount Total Date Amount
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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DATE .NO .
The undersigned applies for the construction of a particular sewer connecting No _
Street and hereby agrees to comply with the Rules and Regulations governing the construction
Sewers.as now or at any future time established by the Board of Selectmen.
Am't of estimate $ .
Am't Paid $.
Sketch of Service Here
I I
a nd use of Particular
__Owner
Connection made in Street.
Remarks:
Work completed .._19..