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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DATE ....................•.._.
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The undersi gned applies for the consIruction of a pa rlieular sewer connecling No.....•..•....••.•••"......
Street and hereby agrees to compIy with th e Rules and Regulations governing the construeIi on and use of Partie u Ia r
Sewers,as now or aI any future Ii me estabIished by the Board of Selectmen.
Am'1 of estimale $., . , ,..., ,
Am't Paid $.., , . ,..
..,..••, ,Owner
Sketch of Service Here
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Connection made in .....•',............•....•....Street.
Remarks:
Work completed •••• ••••••••, •••19..
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