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Address
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Kind of Pipe Size Size of i\-lain
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DATE 4t
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS
WATER DIVISION
The uudei'signed applies for a supply of ;Yater at Ko.St,and hereby agrees t.o
eomply with the l'ules and regulations as now,or at.an:,iut.ure time,est.ablished by the Board of Seieetmen,
.....'\m't.of E:::.;tinlate 8 _Owner -----------------
Am't,Paid S _Address
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Sketch of S crvke Here
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