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The undersi gned a ppl ies for the construction of a particular sewer connecting No.."'..............
.~St~eet and hereby agrees to comply with the Rules and Regulation~governing the construction and use of P:'rticular
Sewers.as no\oV or at:any future time established by the Board of Selectmen.
Am't of estinnat:e $...
NO......•.•.DATE .
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t TOWN Of LEXINGTON-DEPT.OF PUBLIC WORKS 1
t SEWER DIVISION 1
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Am't Paid $.. . ...,.
."Owner
Sketch of Service Here
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Connection made ;n Street.
Remarks:
Work completed • •. . . . . . •• . . . ...J9 ••