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TOWN OF LEXINGTON-DEPT.·OF PUBLIC WORKS
SEWER DIVISION
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DATE .......•_ _ _ _•...........NO.••.••••••
The undersig ....ed applies for the construction of a particular sewer connecting No................•..........
Street and hereby agrees to comply with the Rules and Regulations governing the construction and use of Particular
se"",ers.as nrnN or a ..any fulure time established by the Board of Selectmen.
Arn't of estimate $__.
Am't Paid $..._••_ _•......
."Owner
Sketch of Service Here
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Conneetion made ir1._.... . . . . . • • ..•,•.. • • • • . .•. . •..Street.
Remarks:
Wark completed • ,,.19.•