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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 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 $.
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Sketch of Service Here
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Connection made in :........Street.
Remarks:
'Work completed 19