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DATE •:
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies for a snpply of water at Ko.St.and hereby agrees to
comply with the rules and regulations as now,or at any future tim€,established by the Board of Selectmen.
Am't.of Estimate $ _
Am't.Paid $~._
O,vner
Address
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Buildel'_
Sketch of Senicf Here
Connectjon made in Street.
Remarks:
WOl'k completed _19
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