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Date Amount Total Date Amount
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DATE----------eTOWNOFLEXINGTON-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 future time,established by the Board of Selectmen.
Am't.of Estimate $-----Owner
Am't.Paid $_Address
Builder _
Sketch of Service Here~'"'.....,
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Connection made in Street.
Remarks:
Work completed _19