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Address 4e 5c:.rciing Ho;..;,Q
Service No.EO 101..00
Kind of Pipe Size Size of Main
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DATE 41
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
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 fu ture time,established by the Board of Selectmen.
____________Street.
,'\m't.of Estimate S _
Am·t.Paid £._
Buildu _
Connection made in.
Ren1arks:
Owner
Address
Sketch of Service Here
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VI'ork completed .....:........----'-------IS
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