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TOWN OF LEXINGTON-DEPT.OF PUBLIC WORKS
SEWER DIVISION
I,DATE....•...•...••••......•••NO .
The unclersigned a pplies for the construction of a parlicuIar sewer connecting No... . . . _. . . . . . .
Street and hereby agrees to comply with the Ru les and Regulations govem ing 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 Service Here a p
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Connection made in ••...........•.................Street.
Remarks:
Work completed.. . . . . . ... . ......19..