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Address S<7;Y t/I
Kind of Pipe
Repair-RenewaJ.-New Service
Location
Size
Service No...3'6S
Size of Main
Location
Da~e
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JlrlateriaJ
Labor
Amount
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Total I Date !AmQURt
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DATE •
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies for a suppJ:,'of water at No.St.and hereby agrees to
comply with the rules and regulations as now,or at any future time,established by the Board of Selectmen.
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Work completed _
Owner
Address
Sketch of Service Here
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______________Street.Connection made in
Remarks:
Am't.Paid S
Am't.of Estimate $