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Date .Materi.1 Amount Total D.te Amount
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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DA.TE..~..•..........•......•.NO.....••••••
The undersillnedapplies for the construction of a pariicular sewer connectinil No... . . ..,.•. . . . . . . . • . • . . • • . • .
Street and hereby allrees to compl y wi Ih the Rul es and RellulaIions lloverning the ocns1 ruction a nd use of Particular
Sewers,as now or at any tulure ti me establ ished by !tie Board of Selectmen.
Am't of estlmRte $ .
Amtt Paid $.
.'"Owner
Sketch of Service Ha..203
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Connection !TIlde In .•.•••.••.•.•..•......•.." . ...Street.
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Work completed ..........•.•••..19..