Assessment of Cesspools on Hawaiian Home Lands

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* 1. Contact Information

Name *

Address

Address 2

City/Town

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Your Lot Number

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* 3. Is there a Cesspool or other onsite sewage disposal system on your homestead lot

My homestead has an active cesspool(s)

My homestead has an inactive cesspool(s)

My homestead has a septic tank or other onsite sewage disposal system

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* 4. Location of cesspool or onsite sewage disposal system

Front Yard

Back Yard

Side Yard

Not Sure

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* 5. Special Instructions for access (survey team may ask follow up questions about age and use of cesspool)

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* 6. Best Day(s) and Time(s) for DHHL or DHHL Contractor to visit your homestead to assess your active or inactive cesspool -or- Onsite sewage disposal system

Date / Time

Date

Time

AM/PM

Date / Time

Date

Time

AM/PM

Date / Time

Date

Time

AM/PM