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r .TOWN OF LEXINGTON-·BOARD OF PUBLIC WORKS ...--..~
-SEWER DIVletON
OATE _NO _
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The undersigned applies for the oonstruetion of a particular 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 elltablished by the Board of Selectmen.
Am't.of Estimate $_
Am't.Paid $_
_Owner
Sketeh of Service Here •
~_.
Connection made in Street.
Remarks:,
Work completed 19
•__.,L._.__.~._~........__