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DATE •
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies fal'a supply of water at ::\0.St.and hereby agrees to
comply with the rules and regulations as now,or at any future time,established by the Board of Selectmen.
Am't.of Estimate $_
Am't.Paid $_
Buildcr _
Ovmer
Address
Sketch of Sel"Vice Here •
Connection made in Street.
Remarks:
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W'H"k completed _19 •