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DATE ---,
TOWN OF LEXINGTON-BOARD OF PUBLIC WORKS •.
WATER DIVISION
The undersigned applies for a suppl,r 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 $_
Am't.Paid 5
Owner
Address
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Builder _
Sketch of Senice Here
Connection made in Street.
Remark.s:
Work completed _19
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