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Date I jot atenal
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DATE •
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies for a supply of water at No.St.and hereby agrc€s to
comply with the rules and regulations as now,or at any ftlture time,established by the Board of Selectmen.
Am't.of Estimate $,_Owner
Am't.Paid $_Addr€ss
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Connection made in Street,
Ren1urks:
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