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Date Material Amount.Total Date Amount
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I TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
.'.",~«,SEWER DIVISION
DATE.,.,.,.....,..,,,...,...f'lO...".....
t The undersigned applies for the constructiOn of a particular sewer connecting No.,.......• • •••••........•••
Street and hereby agrees to comply with the Rules and Regulations governing the ccnstruction and use of Particular
Sewers.as now or at any futu re ti me established by the Board of Selectmen.
Am't of estimate $.
\.Am't Paid $,..
;
...................................Owner
Sketch of Sel'Yice Here
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Connection made in ... . . . . . . . . . . . • . . . . . . . . . . . . ...Street.
Remark"
Work completed . . • . • • ••• • • • • ••.,9.•
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