A combined sewer is a type of gravity sewer with a system of pipes, tunnels, pump stations etc. to transport sewage and urban runoff together to a sewage treatment plant or disposal site. This means that during rain events, the sewage gets diluted, resulting in higher flowrates at the treatment site. Uncontaminated stormwater simply dilutes sewage, but runoff may dissolve or suspend virtually anything it contacts on roofs, streets, and storage yards. As rainfall travels over roofs and the ground, it may pick up various contaminants including soil particles and other sediment, heavy metals, organic compounds, animal waste, and oil and grease. Combined sewers may also receive dry weather drainage from landscape irrigation, construction dewatering, and washing buildings and sidewalks. 
Combined sewers can cause serious water pollution problems during combined sewer overflow (CSO) events when combined sewage and surface runoff flows exceed the capacity of the sewage treatment plant, or of the maximum flow rate of the system which transmits the combined sources. In instances where exceptionally high surface runoff occurs (such as large rainstorms), the load on individual tributary branches of the sewer system may cause a back-up to a point where raw sewage flows out of input sources such as toilets, causing inhabited buildings to be flooded with a toxic sewage-runoff mixture, incurring massive financial burdens for cleanup and repair. When combined sewer systems experience these higher than normal throughputs, relief systems cause discharges containing human and industrial waste to flow into rivers, streams, or other bodies of water. Such events frequently cause both negative environmental and lifestyle consequences, including beach closures, contaminated shellfish unsafe for consumption, and contamination of drinking water sources, rendering them temporarily unsafe for drinking and requiring boiling before uses such as bathing or washing dishes.
Mitigation of combined sewer overflows include sewer separation, CSO storage, expanding sewage treatment capacity, retention basins, screening and disinfection facilities, reducing stormwater flows, green infrastructure and real-time decision support systems.
This type of gravity sewer design is less often used nowadays when constructing new sewer systems. Modern-day sewer designs exclude surface runoff by building sanitary sewers instead, but many older cities and towns continue to operate previously constructed combined sewer systems.