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Date MaterIal Amount Total Date I --"Amount
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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
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DATE•••.•••.•••.••.••••••••••NO...•••...••
The undersigned appl ies for the construction of a partieular sewer ccnnecting No..... . . . . . . . . . . . . . . . . . . . . • . .
Street and hereby agrees to comply with the Rules and Regulat ions governing the ccnstruction a nd use of Particular
sewers,as now or at any futu re time estabIished by the Board of Selectmen.
Arn't of estimate $ .
Arn't Paid $.
..'"Owner
Sketch of Sen-ice Here
Connection made in.. .... . . .... . . . . . . . . . • . . . . . . . . .Street.
Remarks:
Work completed.. . . . . . . . . . . . . . . . 19..