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.

Sewage treatment is a type of wastewater treatment which aims to remove contaminants from sewage to produce an effluent that is suitable to discharge to the surrounding environment or an intended reuse application, thereby preventing water pollution from raw sewage discharges. Sewage contains wastewater from households and businesses and possibly pre-treated industrial wastewater. There are a high number of sewage treatment processes to choose from. These can range from decentralized systems to large centralized systems involving a network of pipes and pump stations which convey the sewage to a treatment plant. For cities that have a combined sewer, the sewers will also carry urban runoff (stormwater) to the sewage treatment plant. Sewage treatment often involves two main stages, called primary and secondary treatment, while advanced treatment also incorporates a tertiary treatment stage with polishing processes and nutrient removal. Secondary treatment can reduce organic matter from sewage,  using aerobic or anaerobic biological processes. A so-called quarternary treatment step can also be added for the removal of organic micropollutants, such as pharmaceuticals. This has been implemented in full-scale for example in Sweden.