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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
OATE,.•.•...•...••.•••....•••NO......•..._
The ur\cle rsigned applies for lhe construct;on of a particu1ar sewer connecting No..... . . . . .,. . . . . . . . . . . . . . . . .
Street and hereby agrees to comply with the Rules and Regulations governing the construction and use of Particular
Sewers.as now or at any future time established by the Board of Selectmen.
Am't of estimate $ .
Am't Paid $_..
...."Owner
Sketch of Senice Here ~d
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Connection made in,.,. . . . . . . . . . . . ....... . .... . ...Street.
Remarks:
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Work completed.. . . . . _ . . . . . . . ...19..
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