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:-J~_9.'411
DATE
TOWN OF LEXINGTON -BOARD OF PUBLIC WORKS
WATER DIVISION
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The undersigned applies for a supply 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.
Am't of Estimate $.
AIn't Paid $.
Builder .
Owner ..
Address ..
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Sketch of Service Here
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Connection made in street.
Remarks:
Work completed 19