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Kinct of Pipe
Location
Size tf,n Size of Main i"
7 $,..R.x-1]1[N_Semee Location
Date Material Amount Total Date Amount
, a J::l ,INSTALLED BY D~"""OPER
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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
DATE •..••.••.•••..•••••••••••NO.........•.
The undersigned applies for the construction of a particul ar sewer connecllng No... . . . . . ... . . . . . . . . . . . . . . ..•
Street and hereby agrees to comply with the Rules and Regulations governlng the construction and use of Particular
Sewers,as now or at any future tlme established by the Board of Selectmen.
Am't of estimate $.., ,...
Am't Paid $......,'".
..Owner
Sketch of Se....ice Here
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Connection made In , . . . . ..•Street.
Remarks:
Work completed."..••......•...19..