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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DATE .•...••.••.•••..••NO~.....~......
The undersigned applies for the construcl1on of a particular sewer connecting No.•....••.......•..••••••••
Street and hereby agrees to comply with the Rules and Regulatioos governing the construction and use of Particular
Sewers.as now or at any fu ture tjme established by the Board of Selectmen.
Arn't of estimate $.........•
Am't Paid $.
.Owner
Sketch of Serviee Here FOR"2'1
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Connection made in ........•.•.......•..•........Street.
Remarks:
Work completed 19..