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Name
Address
Kind of Pipe
Repair-Renewal-New Service
MateJ'ial
Labor
Amount
...._-,.._--,..-
Location
Size
Total
~W/7 Ji
Date
,
:i
I
1
1
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II,
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Service No.tPO
Size of Ma.in
Location
Am(1
DATE •
TOWN OF LEXINGTON -BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies for a supply of water at No._..._SL and hereby agrc'os to
mpl.v with th(~ruh~f:;,and t'egulatioIl~as now,or at any future time,<:~~.;tablished by UH~IJoard of SekeirncIl.
n't.of Estimate *__
n't.Paid ~
,ildcr _
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Owner
AddnlS»
Sketch of Service Here
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rl'rlcttion rna
marks:
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1 I '-J --.F.i''~lb .'i --I-'----------~,,-/Vr..-I -T ' .1--,
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