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Date Material Amount Total Date Amount
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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DATE .•..••..••..••••••.•.••••NO .
The undersigned applies for the construct;On of a particu;ar sewer connecting No... . . . . . . . . . _ _ . . . . . . . . . . . . . .
Street and hereby agrees to comply with the Rules and Regulations governing the construction and use of Particular
$ewers,as now or at any futu re time estabIished by the Soard of Selectmen.
Am't of estimate $ .
Am't Paid $.
.....................•_.••__..•...Owner
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Sketch of Service Here ,I
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11 I I I I I I I I I I 11 I I I I I I I I I I I I I I ..I r, ,
Connection made in.. . . . . . . . . . . . . . . . . . . . . . . . . . . ...Street.
Remarks:
Work completed..._.._ . _.•......19..