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Date
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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 hm'eby agrees to
comply with the rules and regulations as now,or at any future time,established by the Bom'd of Selectmen.
Am't.of Estimate $_Ownel'
Am't.Paid S _Address
Bllilder _
Sketch of Senice Here •
•19Workcompleted_
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